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"It is deplorable and outrageous that this state's prisons appear to have become a repository for a great number of its mentally ill citizens. Persons who, with psychiatric care, could fit well into society, are instead locked away, to become wards of the state's penal system. Then, in a tragically ironic twist, they may be confined in conditions that nurture, rather than abate, their psychoses."
- Judge William Wayne Justice, Ruiz v. Johnson, 37 F. Supp.2d 855 (S.D. Texas, 1999).
Somewhere between two and three hundred thousand men and women in U.S. prisons suffer from mental disorders, including such serious illnesses as schizophrenia, bipolar disorder, and major depression. An estimated seventy thousand are psychotic on any given day. Yet across the nation, many prison mental health services are woefully deficient, crippled by understaffing, insufficient facilities, and limited programs. All too often seriously ill prisoners receive little or no meaningful treatment. They are neglected, accused of malingering, treated as disciplinary problems.
Without the necessary care, mentally ill prisoners suffer painful symptoms and their conditions can deteriorate. They are afflicted with delusions and hallucinations, debilitating fears, extreme and uncontrollable mood swings. They huddle silently in their cells, mumble incoherently, or yell incessantly. They refuse to obey orders or lash out without apparent provocation. They beat their heads against cell walls, smear themselves with feces, self-mutilate, and commit suicide.
Prisons were never intended as facilities for the mentally ill, yet that is one of their primary roles today. Many of the men and women who cannot get mental health treatment in the community are swept into the criminal justice system after they commit a crime. In the United States, there are three times more mentally ill people in prisons than in mental health hospitals, and prisoners have rates of mental illness that are two to four times greater than the rates of members of the general public. While there has been extensive documentation of the growing presence of the mentally ill in prison, little has been written about their fate behind bars.
Drawing on interviews with correctional officials, mental health experts, prisoners and lawyers, this report seeks to illuminate that fate. We identify the mentally ill in prison - their numbers, the nature of their illnesses, and the reasons for their incarceration. We set out the international human rights and U.S. constitutional framework against which their treatment should be assessed. We review their access to mental health services and the treatment they receive. We examine the various levels of care available to them, their confinement in long-term segregation facilities, the way prisons respond to their self-mutilation and suicide attempts, and the services they receive upon release from prison.
Our research reveals significant advances in mental health care services in some prison systems. Across the country there are competent and committed mental health professionals who struggle to provide good mental health services to those who need them. They face, however, daunting obstacles - including facilities and rules designed for punishment. The current fiscal crisis in states across the country also threatens the gains that have been made.
Our research also indicates the persistence in many prisons of deep-rooted patterns of neglect, mistreatment, and even cavalier disregard for the well-being of vulnerable and sick human beings. A federal district judge, referring in 1999 to conditions in Texas' prisons, made an observation that is still too widely applicable:
Whether because of a lack of resources, a misconception of the reality of psychological pain, the inherent callousness of the bureaucracy, or officials' blind faith in their own policies, the [corrections department] has knowingly turned its back on this most needy segment of its population.
In the most extreme cases, conditions are truly horrific: mentally ill prisoners locked in segregation with no treatment at all; confined in filthy and beastly hot cells; left for days covered in feces they have smeared over their bodies; taunted, abused, or ignored by prison staff; given so little water during summer heat waves that they drink from their toilet bowls. A prison expert recentlydescribed one prison unit as "medieval…cramped, unventilated, unsanitary…it will make some men mad and mad men madder." Suicidal prisoners are left naked and unattended for days on end in barren, cold observation cells. Poorly trained correctional officers have accidentally asphyxiated mentally ill prisoners whom they were trying to restrain.
Offenders who need psychiatric interventions for their mental illness should be held in secure facilities if they have committed serious crimes, but those facilities should be designed and operated to meet treatment needs. Society gains little from incarcerating offenders with mental illness in environments that are, at best, counter-therapeutic and, at worst dangerous to their mental and physical well-being. As another federal judge eloquently noted:
All humans are composed of more than flesh and bone - even those who, because of unlawful and deviant behavior, must be locked away…. Mental health, just as much as physical health, is a mainstay of life. Indeed, it is beyond any serious dispute that mental health is a need as essential to a meaningful human existence as other basic physical demands our bodies may make for shelter, warmth, or sanitation.
Doing time in prison is hard for everyone. Prisons are tense and overcrowded facilities in which all prisoners struggle to maintain their self-respect and emotional equilibrium despite violence, exploitation, extortion, and lack of privacy; stark limitations on family and community contacts; and a paucity of opportunities for meaningful education, work, or other productive activities. But doing time in prison is particularly difficult for prisoners with mental illness that impairs their thinking, emotional responses, and ability to cope. They have unique needs for special programs, facilities, and extensive and varied health services. Compared to other prisoners, moreover, prisoners with mental illness also are more likely to be exploited and victimized by other inmates.
Mental illness impairs prisoners' ability to cope with the extraordinary stresses of prison and to follow the rules of a regimented life predicated on obedience and punishment for infractions. These prisoners are less likely to be able to follow correctional rules. Their misconduct is punished - regardless of whether it results from their mental illness. Even their acts of self-mutilation and suicide attempts are too often seen as "malingering" and punished as rule violations. As a result, mentally ill prisoners can accumulate extensive disciplinary histories.
Our research suggests that few prisons accommodate their mental health needs. Security staff typically view mentally ill prisoners as difficult and disruptive, and place them in barren high-security solitary confinement units. The lack of human interaction and the limited mental stimulus of twenty-four-hour-a-day life in small, sometimes windowless segregation cells, coupled with the absence of adequate mental health services, dramatically aggravates the suffering of the mentally ill. Some deteriorate so severely that they must be removed to hospitals for acute psychiatric care. But after being stabilized, they are then returned to the same segregation conditions where the cycle of decompensation begins again. The penal network is thus not only serving as a warehouse for the mentally ill, but, by relying on extremely restrictive housing for mentally ill prisoners, it is acting as an incubator for worse illness and psychiatric breakdowns.
International human rights law and standards specifically address conditions of confinement, including the treatment of mentally ill prisoners. If, for example, U.S. officials honored in practice the International Covenant on Civil and Political Rights, to which the United States is a party, and the United Nation's Standard Minimum Rules for the Treatment of Prisoners, which sets out detailed guidelines on how prisoners should be treated, practices in American prisons would improve dramatically. These human rights documents affirm the right of prisoners not to be subjected to cruel, inhuman, or degrading conditions of confinement and the right to mental health treatment consistent with community standards of care. That is, human rights standards do not permit corrections agencies to ignore or undertreat mental illness just because a person is incarcerated. The Eighth Amendment to the U.S. Constitution, which prohibits cruel and unusual punishment, also provides prisoners a right to humane conditions of confinement, including mental health services for serious illnesses.
Prisoners are not, however, a powerful public constituency, and legislative and executive branch officials typically ignore their rights absent litigation or the threat of litigation. U.S. reservations to international human rights treaties mean that prisoners cannot bring suit based on violations of their rights under those treaties. Lawsuits under the U.S. Constitution can only accomplish so much. Federal courts have interpreted the U.S. Constitution as violated only when officials are "deliberately indifferent" to prisoners' known and serious mental health needs. Neglect or malpractice are not constitutional violations. In most states, prisoners cannot sue public officials under state law for medical malpractice. Finally, the misguided Prison Litigation Reform Act, enacted in 1996, has seriously hampered the ability of prisoners to achieve effective and timely help from the courts.
Mental health treatment can help some people recover from their illness, and for many others it can alleviate its painful symptoms. It can enhance independent functioning and encourage the development of more effective internal controls. In the context of prisons, mental health services play an even broader role. By helping individual prisoners regain health and improve coping skills, they promote safety and order within the prison community as well as offer the prospect of enhancing community safety when the offenders are ultimately released.
The components of quality, comprehensive mental health care in prison are well known. They include systematic screening and evaluation for mental illness; mechanisms to provide prisoners with prompt access to mental health personnel and services; mental health treatment that includes a range of appropriate therapeutic interventions including, but not limited to, appropriate medication; a spectrum of levels of care including acute inpatient care and hospitalization, long-term intermediate care programs, and outpatient care; a sufficient number of qualified mental health professionals to develop individualized treatment plans and to implement such plans for all prisoners suffering from serious mental disorders; maintenance of adequate and confidential clinical records and the use of such records to ensure continuity of care as prisoners are transferred from jail to prison and between prisons; suicide prevention protocols for identifying and treating suicidal prisoners; and discharge planning that will provide mentally-ill prisoners with access to needed mental health and other support services upon their release from prison. Peer review and quality assurance programs help ensure that proper policies on paper are translated into practice inside the prisons.
Many prison systems have good policies on paper, but implementation can lag far behind. In recent years, some prison systems have begun to implement system-wide reforms - often prompted by litigation - and innovative programs to attend to the mentally ill. Nevertheless, across the country, seriously ill prisoners continue to confront a paucity of qualified staff who can evaluate their illness, develop and implement treatment plans, and monitor their conditions; they confront treatment that consists of little more than medication or no treatment at all; they remain at unnecessarily high risk for suicide and self-mutilation; they live in the chaos of the general prison population or under the strictures of solitary confinement - with brief breaks in a hospital - because of the lack of specialized facilities that would provide the long-term supportive, therapeutically-oriented environment they need.
Providing mental health services to incarcerated offenders is frustrated by lack of resources. It is also frustrated by the realities of prison life. Correctional mental health professionals work in facilities run by security staff according to rules never designed for or intended to accommodate the mentally ill. For example, mentally ill prisoners are consigned to segregated units even though the harsh, isolated confinement in such units can provoke psychiatric breakdown. Moreover, the rules designed by security staff for prisoners in solitary confinement prevent mental health professionals from providing little more than medication to the mentally ill confined in these units; they cannot provide much needed private counseling, group therapy, and structured activities. Correctional staff who have the most contact with prisoners and who are often called upon to make decisions regarding their needs - particularly in the evenings when mental health staff are not present - often lack the training to recognize symptoms of mental illness and to handle appropriately prisoners who are psychotic or acting in bizarre or even violent ways. It is easy for untrained correctional staff to assume an offender is deliberately breaking the rules or is faking symptoms of illness for secondary gain, such as to obtain a release from solitary confinement into a less harsh hospital setting.
Many experts with whom we spoke also noted that, unfortunately, the judgment of some mental health professionals working in prisons becomes compromised over time. They become quick to find malingering instead of illness; to see mentally ill prisoners as troublemakers instead of persons who may be difficult but are nonetheless deserving of serious medical attention. The tendency to limit treatment to the most acutely and patently ill is also encouraged by the lack of resources; since everyone cannot receive appropriate treatment, mental health staff limit their attention to only a few.
* * *
The growing number of mentally ill persons who are incarcerated in the United States is an unintended consequence of two distinct public policies adopted over the last thirty years.
First, elected officials have failed to provide adequate funding, support, and direction for the community mental health systems that were supposed to replace the mental health hospitals shut down as part of the "deinstitutionalization" effort that began in the 1960s.
A federal advisory commission appointed by President George W. Bush, the President's New Freedom Commission on Mental Health, recently reported that the U.S. mental health system was "in shambles." People with serious mental illnesses - particularly those who are also poor, homeless, and suffering as well from untreated alcoholism or drug addiction - often cannot obtain the mental health treatment they need. Left untreated and unstable, they enter the criminal justice system when they break the law. Most of their crimes are minor public order or nuisance crimes, but some are felonies which lead to prison sentences.
Second, elected officials have embraced a punitive anti-crime effort, including a national "war on drugs" that dramatically expanded the number of persons brought into the criminal justice system, the number of prison sentences given even for nonviolent crimes (particularly drug and property offenses), and the length of those sentences. Prison and jail populations have soared, more than quadrupling in the last thirty years. A considerable proportion of that soaring prison population consists of the mentally ill.
There is growing recognition in the United States that the country can ill-afford its burgeoning prison population, and that for many crimes, public goals of safety and crime reduction would be equally - if not better - served by alternatives to incarceration, including drug and mental health treatment programs. Momentum is building, albeit slowly, to divert low-level nonviolent offenders from prison - an effort that would benefit many of the mentally ill. But until the country makes radical changes in its approach to community mental health - as well as poverty and homelessness - there is every likelihood that men and women with mental illness will continue to be over-represented among prison populations.
Corrections officials recognize the challenge posed to their work by the large and growing number of prisoners with mental illness. They recognize they are being asked to serve a function for which they are ill equipped. Most of what we say in this report will not be new to them. We hope our report, and the extensive documentation of human suffering that it contains, will support their efforts to ensure appropriate conditions of confinement and mental health services for the mentally ill men and women consigned to them. We hope it helps marshal political sentiments and public opinion to understand the need for enhanced mental health resources - for those in as well as outside of prison. We also hope it encourages dramatic changes in the use of prisons in the United States - reserving them for dangerous violent offenders who must be securely confined and not for low-level nonviolent offenders. The problems we document in this report can be solved - but to do so requires drastically more public commitment, compassion, and common sense than have been shown to date.
The Scope of this Report
We are keenly aware of the many related problems that we have excluded from this report. Our inquiry is limited to adults, although a high percentage of youth in the juvenile justice system are also mentally ill. We concentrate on mental illness, while recognizing that prisoners who are developmentally disabled or suffer from organic brain damage also face unique and important problems. And our inquiry is limited to prisons, although we acknowledge - as all who are familiar with jails must - that jails are equally, if not more, overwhelmed by mentally ill prisoners for whom they are ill-equipped to care.
There are approximately fourteen hundred adult prisons in the United States, operated by or responsible to fifty state correctional agencies and the federal bureau of prisons. We have not attempted to produce a comprehensive assessment of the treatment of mentally ill prisoners in any one of these prisons or prison systems. Nor have we sought to identify those that deserve praise for the progress they have made in providing mental health services. Rather, we have sought to identify widely, albeit not universally, shared problems and to present illustrative examples. The time period covered in this report is from the mid-1990s to the present. Examples of specific problems in individual prisons presented in this report may have been subsequently addressed by correctional authorities, and, where we are aware of such remedial measures, we have described them.
A Note on Methodology
This report is based on research, interviews, and visits to numerous correctional facilities conducted primarily between 2001 and 2003, although we visited some prisons in earlier years. Human Rights Watch interviewed and/or corresponded with at least three hundred prisoners, mental health experts, prison officials, and lawyers from many parts of the country. We have visited prisons and conducted in-person, on-site interviews with prisoners and staff in California, Colorado, Connecticut, Illinois, Indiana, Minnesota, New York, Ohio, Oklahoma, Pennsylvania, Texas, Vermont, and Washington. We also interviewed by telephone many correctional staff, including mental health professionals, in a number of states whose facilities we did not visit. In the course of our research, we have consulted experts in numerous fields, including psychiatry, psychology, bio-statistics, law, correctional security classifications, prison architecture, suicide protocols, prison mental health care, public health care, community mental health, counseling, and substance abuse treatment. We have also drawn on many other resources, including opinions generated in court rulings; information gathered by court monitors as well as experts hired for court challenges to prison mental health services; academic and professional writing on correctional mental health issues; and unpublished studies.
Prisoners were contacted through advertisements placed in Prison Legal News asking seriously mentally-ill prisoners to write to Human Rights Watch, through attorneys who had been involved in litigating cases on mental illness in prisons, through family members who believed their incarcerated relatives needed mental health help that they were not receiving, and through organizations such as state protection and advocacy groups. The staff at many of the institutions Human Rights Watch visited while researching this report also agreed to provide us access, with prisoner consent, to individuals randomly selected from the mental health caseload and prisoners whose behavior and correctional histories met Human Rights Watch research criteria. Throughout this report, we provide extracts from letters prisoners with mental illness sent us. We have not sought to verify the specific allegations made in them and recognize that some may be embellished or altered in the telling. Nevertheless, the letters are eloquent testimony to the prisoners' sense of their experience. Where prisoners' letters are quoted, we have left in place spelling and grammatical errors.
It is impossible to do justice to the wealth of information accumulated during research for this report without creating a publication that was thousands of pages in length. Yet, because prisons operate in secret, for the most part, it is important for the public to have access to as much material as is possible. We have placed some of the expert reports produced during litigation on our website, as they are not readily available to the public, and reveal, in often harrowing detail, problems with specific prisons regarding the treatment of mentally ill offenders. They can be found at http://www.hrw.org.
No prison system in the United States intentionally harms mentally ill prisoners through a policy of providing substandard care. Nevertheless, poor mental health treatment for mentally ill prisoners is a national reality. The government is responsible for protecting basic human rights, particularly those of the most vulnerable, and making wise use of limited criminal justice resources. Public officials must make the necessary improvements. Public support, particularly in times of tight budgets, is crucial to ensuring officials fulfill their responsibilities.
Prescriptions for quality mental health care in prisons are plentiful. They are found in the standards and guidelines of the American Correctional Association, the National Commission on Correctional Health Care (NCCHC), the Criminal Justice/Mental Health Consensus Project coordinated by the Council of State Governments, in court rulings, expert reports, and in a voluminous professional literature. Little would be served by repeating here all those recommendations. Our research suggests that what is lacking in prison mental health services is not knowledge about what is needed, but the resources and commitment to do it.
We therefore present here three sets of recommendations: one directed at the U.S. Congress specifically; one directed at public officials, community leaders and members of the general public; and one directed at prison officials and their staff.
Recommendations to the U.S. Congress
Human Rights Watch recommends that the U.S. Congress promptly:
1) Enact the Mentally Ill Offender Treatment and Crime Reduction Act
Currently pending before the U.S. Senate and House of Representatives is the Mentally Ill Offender Treatment and Crime Reduction Act introduced by Congressman Ted Strickland and Senator Mike DeWine. If enacted, the bill could catalyze significant reforms across the country in the way the criminal justice system responds to people with mental illness. The bill authorizes grants to help communities establish diversion programs (pre-booking, jail diversion, mental health courts) for mentally ill offenders, treatment programs for mentally ill offenders who are incarcerated, and transitional and discharge programs for mentally ill offenders who have completed their sentences. The grants program would be administered by the Department of Justice in consultation with the Department of Health and Human Services and could be used to help pay for mental health treatment services in addition to program planning and administration, education and training, and temporary housing.
2) Improve access to public benefits covering all needed mental health services.
Congress should tackle serious deficiencies in federal programs that fund mental health services, including problems of limited coverage and access that keep many mentally ill persons from being able to obtain the treatment they need. For offenders released from prisons, current law leads to long delays in the restoration of eligibility for benefits. Relatively simply changes in the rules governing Medicaid, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) would enable ex-offenders with mental illness to avoid those delays and to obtain quickly the ability to pay for needed medication and mental health services in the community and to ensure continuity of care. Rapid restoration of benefits to released offenders with mental illness not only helps them manage their illness; it also supports public safety by reducing the risk of new involvement with the criminal justice system.
3) Amend or repeal the Prison Litigation Reform Act (PLRA)
Human Rights Watch also urges Congress to amend or repeal the Prison Litigation Reform Act (PLRA) which severely hinders prisoners in their efforts to remedy unconstitutional conditions in state correctional facilities. We urge Congress to: 1) modify the excessively stringent exhaustion requirement in the PLRA that requires prisoners to comply with all internal prison grievance procedures and appeals before being allowed to bring a federal lawsuit which frustrates the prosecution of many meritorious prisoner lawsuits; 2) repeal the requirement that judicially enforceable consent decrees contain findings of federal law violations; 3) repeal the requirement that all judicial orders automatically terminate two years after they are issued; and 4) restore special masters' and attorneys' fees to reasonable levels.
Recommendations to Public Officials, Community Leaders and the General Public
Public officials - elected and appointed - must act decisively to improve mental health services in U.S. prisons. An ongoing concern should be reducing the population of prisoners who have severe mental illnesses. Second, public officials must develop standards, provide oversight mechanisms, and mobilize resources to ensure effective, quality mental health care in prisons.
1) Reduce the incarceration of persons with mental illness.
Steps should be taken at the federal, state, and local levels to reduce the unnecessary and counterproductive incarceration of low-level nonviolent offenders with mental illness. Mandatory minimum sentencing laws should be revised to ensure prison is reserved for the most serious offenders (whether or not mentally ill) and prison sentences are not disproportionately harsh. Mental health courts, prosecutorial pretrial diversion, and other efforts should be supported which will divert mentally ill offenders from jails and into community based mental health treatment programs. Reducing the numbers of mentally ill offenders sent to prison will also free up prison resources to ensure appropriate mental health treatment for those men and women with mental illness who must, in fact, be incarcerated for reasons of public safety.
2) Set high standards for prison mental health services.
Public officials must not accept low quality mental health services for mentally ill prisoners. They should set standards higher than the constitutional minimum required under the Eighth Amendment, which permits malpractice even on a massive scale. International human rights standards require officials to ensure the highest attainable standard of mental health, including accessible, acceptable, and appropriate and good quality mental health services, provided by trained professionals. Officials should not tolerate the misery and pain of prisoners whose mental illness is left untreated or undertreated. Quality mental health services in prison will not only help prisoners, but will improve safety within prisons, benefiting others prisoners and staff. Good correctional mental health services will also increase the likelihood that prisoners will be able to return successfully to their communities following release.
3) Improve conditions of confinement.
Public officials must ensure that all prisoners are confined in conditions consistent with their human dignity. No prisoner should be confined in overcrowded, dangerous, filthy, vermin- or bug-ridden, or unbearably hot cells. Such conditions violate the rights of all prisoners, but they have an especially detrimental effect on prisoners with mental illness.
4) Establish effective performance reviews using independent experts.
Public officials cannot exercise their obligation to ensure appropriate mental health services for prisoners if they do not have objective information provided by independent and qualified experts. Correctional officials often do not have an adequate understanding of the limitations on mental health services provided in their prisons, and other elected officials often have even less understanding. Expert reports presented during litigation are often the only way light is shed on prison conditions. Public officials should not wait, however, until an inmate or family member brings a lawsuit. Existing prison accreditation mechanisms-by the American Correctional Association and the National Commission on Correctional Health Care (NCCHC)-focus primarily on the existence of appropriate policies; they do not assess their implementation or the quality of services actually provided. Experience reveals that implementation often lags far behind even the best of policies.
Each prison system should have performance evaluations of its mental health services by independent qualified professionals. The results of those evaluations should be public (with the names of prisoners kept confidential). To be able to undertake the evaluations, the experts should have unfettered access to medical records, staff, and prisoners. The experts should be charged with monitoring the ways in which prisons diagnose and treat prisoners; the availability of qualified staff in numbers adequate for prisoner mental health needs; the availability of appropriate facilities to provide different levels of care; the range of therapeutic interventions provided to prisoners and the extent to which prisoners have access to services, programs, and facilities; and policies and practices concerning the use of disciplinary measures such as administrative segregation and physical restraints to respond to inmates with serious mental illnesses.
5) Establish comprehensive internal quality review mechanisms for each prison system and prison.
Quality controls for mental health services are often rudimentary, ineffective, or nonexistent. Mental health staff often lack an effective opportunity to engage in candid self-criticism, gather data, identify and discuss shared problems, and work with senior corrections officials to develop solutions to problems in the delivery of mental health services. Establishment of internal quality review procedures and the commitment of prison officials and mental health staff to effectively implement those procedures will provide a vital and ongoing complement to external quality assurance audits.
6) Solicit and heed prisoners' concerns.
As consumers of mental health services, prisoners are singularly without power to protest poor treatment. They cannot switch to another provider, and their legitimate complaints and concerns are rarely acknowledged, much less responded to by corrections officials. Prisons should establish at an institutional as well as departmental level procedures by which prisoner perspectives about mental health services (indeed all medical services) are solicited and heeded. Prisoner views should be incorporated into the outside as well as internal quality review mechanisms recommended above. Special prisoner mental health grievance systems should be established predicated on recognition that prisoners are mental health service consumers and their concerns warrant prompt, careful responses. Current grievance mechanisms are difficult to comply with, rarely result in any meaningful response, and can prompt retaliation from staff. Mentally ill prisoners can have a particularly difficult time following the rules regarding grievances and meeting grievance procedure deadlines. If prison systems attended to prisoner concerns - at the very least communicating to them that they are being listened to - this could well have a beneficial impact on the prisoners' adherence to treatment plans, medication compliance, and other measures critical to their health. If other prisoner-responsive quality control mechanisms are not available, we also recommend the creation of an impartial external entity (within individual prisons or system-wide) staffed with persons with mental health expertise to evaluate prisoner complaints regarding mental health care and treatment.
7) Support funding for appropriate prison mental health services.
We recognize that even corrections departments are not immune from the budget slashing occasioned by current fiscal crises. But even in the best of times, it is difficult to secure adequate funding for services and programs for prisoners. Improvements in mental health services in prison are, unfortunately, heavily dependent on financial resources. Qualified, competent staff cannot be hired and retained in sufficient numbers absent funding. Governors must support adequate funding levels for mental health services and permit corrections officials and mental health staff to argue forcefully, extensively, and publicly on behalf of such funding. They must present candid analyses to the public of existing problems with correctional mental health treatment, the consequences of those problems and the need for resources to address them. They should encourage legislators to reduce prison populations, by lowering unnecessarily harsh mandatory sentencing laws and by supporting alternatives to incarceration for low-level nonviolent offenders, rather than by cutting indispensable services for those prisoners who must be incarcerated.
Recommendations to Prison Officials and Staff
Correctional agencies need to act decisively to improve the delivery of mental health services in prisons and prison systems. We recommend they:
1) Provide sufficient numbers of qualified prison mental health staff.
- Quality mental health services cannot be provided without sufficient numbers of qualified staff with different areas of expertise (from occupational therapists to psychiatrists). Determination of optimal staffing levels should be based on assessment of accurate data regarding prisoner demographics, mental health histories, and service utilization. Each prison system should have department-wide internal credential requirements for mental health staff, and effective mechanisms for monitoring mental health staff competency, performance, and compliance with official protocols and procedures. Mental health staff should be provided and encouraged to engage in ongoing professional education to keep up to date in their fields.
- Recruiting qualified, competent mental health staff is often frustrated by salaries that are below community levels. Low pay also contributes to high rates of staff turnover, which diminishes the quality of care provided. Prison systems and agencies contracted to provide prison medical and mental health services should create employment incentives and introduce competitive pay rates comparable to those offered in community mental health settings, to reduce staff turnover. For prisons in out-of-the-way, undesirable locations, additional incentives ought to be provided to hire and retain quality staff.
2) Provide mental health training for correctional staff.
·It is counterproductive and dangerous for correctional staff who have little or no training in mental illness to work in housing units, on the yards, and elsewhere in prison with prisoners who have serious mental illnesses. Effective training should be provided to all new officers in such areas as: signs of mental illness; different treatments for mental illnesses; side-effects of medications used for the treatment of mental illnesses; effective interaction with mentally ill prisoners; defusing potentially escalating situations; recognition of the signs of possible suicide attempts; and training on the safe use of physical and mechanical restraints for mentally ill offenders. Additional information pertinent to working with mentally ill prisoners should be provided during in-service training.
- Staff should be trained to view suicide attempts and extreme acts of self-mutilation as probable signs of mental illness rather than as indications that prisoners are "malingering" or acting-out simply to gain attention or to be temporarily removed from their cell. Staff should be given guidance, working with mental health staff, to better distinguish between prisoners who deliberately and consciously break rules and undermine prison security, and prisoners whose conduct reflects a serious mental illness.
- Senior officials should carefully monitor the conduct of custodial staff, take seriously prisoner allegations of misconduct, and investigate individual cases as well as patterns of staff misconduct. Staff should be held individually accountable for mistreating prisoners. But prison officials should not rely solely on disciplinary mechanisms for individual staff. They should use their institutional authority to communicate forcefully that mistreatment will not be condoned, to reassign or more closely monitor problematic staff, and to provide better training.
3) Ensure sufficient specialized facilities for seriously mentally ill prisoners.
- Corrections departments should ensure they have a sufficient number of hospital beds and acute care facilities to meet the needs of the prison population. Prisoners with serious mental health needs should not be removed from such facilities simply to free up space for others; nor should prisoners have to wait to be able get the services they need because of insufficient beds. Prisoners with mental illness who have been in acute care facilities should be placed in "step-down" or transitional programs before they are returned to the general prisoner population. Corrections departments should also establish additional intermediate care facilities to provide mentally ill prisoners who have sub-acute care needs with more intensive and long-term mental health services in a more supportive and structured setting than is available to the general population. While not all of those who are seriously mentally ill need to be, or should be, housed in separate facilities, states need to have sufficient specialized facility space available to accommodate those whom the mental health teams determine would benefit from such housing.
- States should focus more resources on providing specialist mental health facilities for seriously mentally ill female prisoners. Since the absolute number of women prisoners is much smaller than that of male prisoners, states frequently lack comprehensive mental health facilities for their female prisoners.
4) Ensure mental health input and impact in disciplinary proceedings.
Prisoners with mental illness can have unique difficulties complying with prison rules and may engage in bizarre or disruptive behavior because of their illness. Punitive responses to such conduct do little to reduce or deter it. When prisoners who are on the mental health caseload violate rules, disciplinary procedures should require mental health input to the disciplinary officers regarding whether the prisoner's behavior was connected to or caused by mental illness, and regarding what sanctions might be appropriate. In specialized units housing only mentally ill prisoners, corrections officials should work with mental health staff to determine whether the normal prison disciplinary system should be suspended, and mental health staff should determine appropriate responses to prisoner misconduct consistent with his or her mental diagnosis and treatment plan.
5) Exclude the seriously mentally ill from segregated confinement or supermax prisons.
Human Rights Watch opposes the prolonged and unnecessary incarceration of any prisoner in isolated segregation or supermaximum security units. Prisoners with serious mental illnesses, even if they are currently stabilized or asymptomatic, should never be confined for prolonged periods in the harsh isolation conditions typical of segregation or supermax prisons. There is an unacceptably high risk that the isolation, reduced mental stimulus, lack of structured activities, and the absence of social interaction will provoke a deterioration of their symptoms and increased suffering. We recognize there are some prisoners with mental illness who require extreme security precautions even when under mental health treatment. For these individuals, prisons should provide specialized secure units that ensure human interaction and purposeful activities in addition to mental health services.
Corrections officials should also make sure that all prisoners in segregated housing have their mental health monitored carefully and continually; that they be able to communicate confidentially with mental health staff; and that they have access to whatever services and therapeutic interventions mental health staff determine are necessary. To the extent that accommodating mental health needs requires changes in regular rules and protocols governing prisoners in isolation, the changes should be undertaken consistent with reasonable security requirements.
6) Develop and expand continuity-of-care protocols between prisons and the community.
Prisons and community mental health systems need to develop comprehensive continuity-of-care protocols and programs to break the cycle of release-recidivism-reincarceration. Prisoners that have serious mental illnesses should be released from prison with arrangements in place to provide them with access to medication and mental health services. Moving the prisoners prior to their release to prisons in or near the counties to which they will return will allow prison mental health staff and parole officers to liaise more effectively with local mental health service providers to guard against the prisoner falling through the cracks. Discharge planning efforts should begin months prior to a seriously mentally ill prisoner's release. Corrections agencies should also establish procedures by which prisoners with mental illness will have access to Medicaid immediately upon release rather than having to wait for months to have the paperwork completed. States and counties should increase the number of programs providing housing and assisted living facilities for newly released prisoners with mental illness.
"By default, we get forced to be a pseudo[mental] hospital."
Michael Mahoney, warden, Montana State Prison
"On any given day, at least 284,000 schizophrenic and manic depressive individuals are incarcerated, and 547,800 are on probation. We have unfortunately come to accept incarceration and homelessness as part of life for the most vulnerable population among us."
Congressman Ted Strickland
"We are literally drowning in patients, running around trying to put our fingers in the bursting dikes, while hundreds of men continue to deteriorate psychiatrically before our eyes into serious psychoses…"
Unnamed prison psychiatrist
A staggering number of persons with mental illnesses are confined in U.S. jails and prisons - somewhere between two and four hundred thousand or more, according to expert estimates. The causes of this massive incarceration of the mentally ill are many, but corrections and mental health professionals point primarily to inadequate community mental health services and the country's punitive criminal justice policies. While mental health hospitals across the country were shut down over the last couple of decades as part of the process of "deinstitutionalization," the community-based health services that were supposed to replace them were never adequately developed. As a consequence, many of the mentally ill, particularly those who are poor and homeless, are unable to obtain the treatment they need. Ignored, neglected, and often unable to take care of their basic needs, large numbers commit crimes and find themselves swept up into the burgeoning criminal justice system. Jails and prisons have become, in effect, the country's front-line mental health providers.
Most of the mentally ill who end up in prison are initially incarcerated in jail as pretrial detainees. By all accounts, jails across the country are even less able to care for mentally ill prisoners than prisons. Absent adequate mental health screening and services in jails, the prison systems inherit exacerbated mental health problems when the pretrial detainees suffering from mental illnesses are ultimately sentenced and moved from jail into prison.
Indeed two of the largest mental health providers in the country today are Cook County and Los Angeles County jails, both of them urban entry points into the burgeoning prisons systems of Illinois and California respectively. Based on a sample of Cook County jail inmates, Northwestern University psychology professor Linda Teplin reported in 1990 that over 6 percent of inmates were actively psychotic, a rate four times that found in the outside population.
Rates of Incarceration of the Mentally Ill
Persons with mental illness are disproportionately represented in correctional institutions. While about 5 percent of the U.S. population suffers from mental illness, a 1998 reported noted that "studies and clinical experience indicate that somewhere between 8 and 19 percent of prisoners have significant psychiatric or functional disabilities and another 15 to 20 percent will require some form of psychiatric intervention during their incarceration." In 2000, the American Psychiatric Association reported research estimates that perhaps as many as one in five prisoners were seriously mentally ill, with up to 5 percent actively psychotic at any given moment. Given the current U.S. prison population, this means there may be approximately 300,000 men and women in U.S. prisons today who are seriously mentally ill, and 70,000 who are psychotic. The National Commission on Correctional Health Care issued a report to Congress in March 2002 in which it presented the following prevalence estimates:
On any given day, between 2.3 and 3.9 percent of inmates in State prisons are estimated to have schizophrenia or other psychotic disorder, between 13.1 and 18.6 percent major depression, and between 2.1 and 4.3 percent bipolar disorder (manic episode). A substantial percentage of inmates exhibit symptoms of other disorders as well, including between 8.4 and 13.4 percent with dysthymia, between 22.0 and 30.1 percent with an anxiety disorder, and between 6.2 and 11.7 percent with post-traumatic stress disorder.
In 1999, the federal Bureau of Justice Statistics, drawing on a survey in 1997 of adult prisoners, estimated that 16 percent of state and federal adult prisoners and a similar percentage of adults in jails were mentally ill. This prevalence rate translates into an estimated 230,505 adults with mental illness confined in U.S. prisons, and another 106,476 in its jails. The Bureau of Justice Statistics has also reported that nearly one in ten prisoners are taking psychotropic medications, with that number increasing to nearly one in five in Hawaii, Maine, Montana, Nebraska, and Oregon.
As these numbers suggest, prisons have become warehouses for a large proportion of the country's men and women with mental illness. In September 2000, Congressman Ted Strickland informed his colleagues on the House Subcommittee on Crime that between 25 and 40 percent of all mentally ill Americans would, at some point in their lives, become entangled in the criminal justice system. According to the American Psychiatric Association, over 700 thousand mentally ill Americans are processed through either jail or prison each year. In 1999, NAMI (formerly known as the National Alliance for the Mentally Ill) reported that the number of Americans with serious mental illnesses in prison was three times greater than the number hospitalized with such illnesses.
Individual prison systems report high percentages of mentally ill offenders. For example, the California Department of Corrections estimated that as of July 2002, 23,439 prisoners were on the prison mental health roster, representing over 14 percent of the California prison population. The Pennsylvania Department of Corrections estimates that 16.5 percent of its prisoner population, or approximately 6,500 people, are on the mental health caseload, of whom 1,537 are so ill that their ability to function on a day-to-day basis has been dramatically limited. Eleven percent of New York's sixty-six thousand prisoners receive mental health services. In Kentucky, 14.6 percent of the state prison population is on the mental health caseload, and in Texas the figure is 11.6 percent.
There are no national statistics on historical rates of mental illness among the prison population. Some states, however, report a significant increase in recent years in the proportion of prisoners diagnosedwith serious mental illnesses. For example, the mental health caseload in New York prisons has increased by 73 percent since 1991, five times the prison population increase. In Colorado, the proportion of prisoners with major mental illness was 10 percent in 1998, five to six times the proportion identified in 1988. Between 1993 and 1998 the population of seriously mentally ill prisoners in Mississippi doubled and in the District of Columbia it rose by 30 percent. In Connecticut, the number of prisoners with serious mental illness increased from 5.2 percent to 12.3 percent of the state's prison population. Indeed, nineteen of thirty-one states responding to a 1998 survey by the Colorado Department of Corrections reported a disproportionate increase in their seriously mentally ill population during the previous five years. While most mental health professionals we interviewed believe that there has been some increase in the proportion of prisoners who are mentally ill, they caution that the dramatic increases noted above may also reflect improvements in the mental health screening and diagnosis of prisoners.
Deinstitutionalization, Crime and Punishment, and the Rise in the Mentally Ill Prisoner Population
Fifty years ago, public mental health care was based almost exclusively on institutional care and over half a million mentally ill Americans lived in public mental health hospitals. Beginning in the early 1960s, states began to downsize and close their public mental health hospitals, a process called "deinstitutionalization." Many factors precipitated the process. The first generation of effective anti-psychotic medications were developed, which made successful treatment outside of hospitals a real possibility. Litigation increased due process safeguards in mental hospital involuntary commitment and release procedures, which meant far fewer people could be committed or kept in the hospitals against their will. Today, fewer than eighty thousand people live in mental health hospitals and that number is likely to fall still further. In 1955, the rate of persons in mental hospitals was 339 per one hundred thousand; by 1998, it had declined to twenty-nine per one hundred thousand.
Deinstitutionalization freed hundreds of thousands of mentally ill men and women from large, grim facilities to which most had been involuntarily committed and in which they spent years, if not decades or entire lives, receiving greatly ineffectual, and often brutal, treatment. Proponents of deinstitutionalization envisioned former mental health hospital patients receiving treatment through community mental health programs and living as independently in the community as their mental conditions permitted. This process was catalyzed by passage of the federal legislation providing seed funding for the establishment of comprehensive mental health centers in the community. Unfortunately, community mental health services have not been able to play the role the architects of deinstitutionalization envisioned. The federal government did not provide ongoing funding for community services and while states cut their budgets for mental hospitals, they did not make commensurate increases in their budgets for community-based mental health services. Chronically underfunded, the existing mental health system today does not reach and provide mental health treatment to anywhere near the number of people who need it.
On July 22, 2003, the President's New Freedom Commission on Mental Health sent its final report to President George W. Bush. The Commission found that:
Mental health delivery system is fragmented and in disarray…lead[ing] to unnecessary and costly disability, homelessness, school failure and incarceration…In many communities, access to quality care is poor, resulting in wasted resources and lost opportunities for recovery. More individuals could recover from even the most serious mental illnesses if they had access in their communities to treatment and supports that are tailored to their needs.
As the Commission's Chairman, Michael F. Hogan, stated in his cover letter with the report:
Today's mental health care system is a patchwork relic - the result of disjointed reforms and policies. Instead of ready access to quality care, the system presents barriers that all too often add to the burden of mental illnesses for individuals, their families, and our communities.
The Commission also found that minority communities were particularly underserved in or inappropriately served by the current mental health care system. It noted that "significant barriers still remain in access, quality, and outcomes of care for minorities….[They are] less likely to have access to available mental health services; are less likely to receive needed mental health care; often receive poorer quality care; and are significantly under-represented in mental health research."
According to the 2002 report of the Criminal Justice/Mental Health Consensus Project, coordinated by the Council of State Governments:
The professionals in the [mental health] system know much about how to meet the needs of the people it is meant to serve. The problem comes, however, in the ability of the system's intended clientele to access its services and, often, in the system's ability to make these services accessible. The existing mental health system bypasses, overlooks, or turns away far too many potential clients. Many people the system might serve are too disabled, fearful, or deluded to make and keep appointments at mental health centers. Others simply never make contact and are camped under highway overpasses, huddled on heating grates, or shuffling with grocery carts on city streets.
Because of the problems plaguing community mental health systems and the limitations on public funding for mental health services, all too many people who need publicly financed mental health services cannot obtain them until they are in an acute psychotic state and are deemed to be a danger to themselves or others. While some of the mentally ill are fortunate to have families with sufficient financial resources to get them private treatment, many of the mentally ill are impoverished. According to NAMI (formerly known as the National Alliance for the Mentally Ill), one in twenty persons with a severe mental illness is homeless. People with serious mental illnesses are over-represented among the homeless population, which comprises the poorest of America's residents: experts estimate than anywhere from 20 to 33 percent of the homeless have serious mental illnesses. People with serious mental illnesses have greater difficulty escaping homelessness than other people; many have been living on the streets for years.
When poor persons with mental illness are able to get treatment, it is typically short-term. People who are hospitalized are often kept for only short periods, until they are stabilized, and then they are released, where they again face limited access to treatment in the community. Persons with mental illness who have prior criminal records or histories of violence have a particularly difficult time getting access to treatment; many mental health programs simply will not take them. According to Richard Lamb, Professor of Psychiatry, Law and Public Policyat the University of Southern California, "it used to be the State Hospital couldn't turn down anybody. Now the state hospitals can and do… It used to be the state hospital was the facility of last resort; and today the jails and prisons are the facilities of last resort."
Community mental health services are especially likely to fail to meet the needs of mentally ill persons with co-occurring disorders. The federal Substance Abuse and Mental Health Services Administration has estimated that 72 percent of mentally ill individuals entering the jail system have a drug-abuse or alcohol problem.Mental health programs are often reluctant to treat persons with substance abuse problems - because of the fear that addicts will prove particularly disruptive and also may try to bring drugs into the programs - and many community mental health staff are not trained to diagnose and treat persons with co-occurring disorders. And, substance abuse programs are often reluctant to take persons who are mentally ill. Despite the prevalence of substance abuse among the mentally ill, few communities have integrated mental health and substance abuse treatment programs.
Deinstitutionalization resulted in the release of hundreds of thousands of mentally ill offenders to communities who could not care for them. At about the same time, national attitudes toward those who committed street crime - who are overwhelmingly the country's poorest - changed markedly. Both the federal and state governments adopted a series of punitive criminal justice policies that encouraged increased arrests; increased the likelihood that conviction for a crime would result in incarceration, including through mandatory minimum sentencing and "three strikes" laws; increased the length of time served, by increasing the length of sentences and reducing or eliminating the availability of early release and parole; and increased the rate at which parolees are returned to prison. The U.S. rate of incarceration soared, becoming the highest in the world: 701 prisoners per one hundred thousand U.S. residents, or one in every 143 residents. Championed as protecting the public from serious and violent offenders, the new criminal justice policies in fact yielded high rates of confinement for nonviolent offenders. Nationwide, nonviolent offenders account for 72 percent of all new state prison admissions. Almost one-third of new admissions are nonviolent drug offenders.
Most of those swept into the criminal justice system are poor, many are homeless, many have substance abuse problems, and many would be good candidates for alternatives to incarceration. Many of them are also mentally ill. In making America's response to crime and drug use more punitive throughout the 1980s and 1990s, state and federal lawmakers inadvertently contributed to the imprisonment of greater numbers of mentally ill citizens. The percentage of America's mentally ill population either living in prison, or having recently come out of prison, increased dramatically.
"Criminalizing the Mentally Ill"
There is a direct link between inadequate community mental health services and the growing number of mentally ill who are incarcerated. As the Criminal Justice/Mental Health Consensus Project noted:
Law enforcement officers, prosecutors, defenders, and judges - people on the front lines every day - believe too many people with mental illness become involved in the criminal justice system because the mental health system has somehow failed. They believe that if many of the people with mental illness received the services they needed, they would not end up under arrest, in jail, or facing charges in court. Mental health advocates, service providers, and administrators do not necessarily disagree. Like their counterparts in the criminal justice system, they believe that the ideal mechanism to prevent people with mental illness from entering the criminal justice system is the mental health system itself - if it can be counted on to function effectively. They also know that in most places the current system is overwhelmed and performing this preventive function poorly.
The President's New Freedom Commission found that across the country the mental health "system's failings lead to unnecessary and costly disability, homelessness, school failure, and incarceration." Every state across the country has its own experience with the "criminalization of the mentally ill." For example, a committee appointed by the state legislature in Maine reported that:
Community mental health services, though very good, are, due to lack of resources, inadequate to meet the needs of persons with mental illness. This has resulted in some persons with mental illness falling through the treatment services net and into the criminal justice system. The lack of community mental health resources also impairs the ability of law enforcement, courts and corrections facilities to divert persons with mental illness away from the criminal justice system and into more appropriate treatment settings.
Thousands of mentally ill are left untreated and unhelped until they have deteriorated so greatly that they wind up arrested and prosecuted for crimes they might never have committed had they been able to access therapy, medication, and assisted living facilities in the community. Mental health professionals told Human Rights Watch that it is next to impossible to get their clients admitted to hospitals or treatment programs until after they have deteriorated to such a point that they have already committed a crime.
The relationship between deinstitutionalization and incarceration is not that of a direct population shift from hospitals to prisons. As described by Pennsylvania psychiatrist Dr. Pogos Voskanian, who works with ex-prisoners in an after-prison program called Gaudenzia House, "deinstitutionalization has created not so much a problem for people who have been deinstitutionalized, but for people who can't get into institutions in the first place." Michael Thompson, lead author of a Criminal Justice/Mental Health Consensus Project report on mental illness in the criminal justice system, agrees that people who might in the past have benefited from publicly provided mental health services are now left untreated until their mental illness deteriorates to the point where they commit a criminal offense and are sent to prison. Some experts use the term "transinstitutionalization" to refer to this problem of persons with mental illness being left untreated until they end up institutionalized within correctional settings.
Mental health professionals also believe the growing number of mentally ill persons in jails and prisons reflects the difficulty of obtaining court orders committing persons with serious mental illness to mental health hospitals. Unless a person poses a clear danger to him or herself or to others, courts will not issue orders for involuntary commitment. In addition, they point to the increased difficulty of obtaining court rulings that mentally ill persons are incompetent to stand trial or of securing verdicts of "not guilty by reason of insanity." As a result persons who are extremely ill, even psychotic, end up in prison.
Economic incentives may also encourage states to channel seriously mentally ill offenders into prisons rather than state hospitals. "State hospitals cost $90-$100,000 per year per patient," said Dr. Fred Maue, chief of clinical services, Pennsylvania Department of Corrections. "In prison, a seriously mentally ill individual is imprisoned and treated for around $35,000. Prison isn't the best place for a mentally ill person to be. But it's better than to just be homeless in the community." Departments of correction have also been better able to protect - and even increase - their budgets in recent years than state agencies with responsibility for social and mental health services. As Mike Robbins, former acting mental health director for the Washington Department of Corrections, told Human Rights Watch:
The mental health agencies of the DHSS [Department of Health and Social Services] have received budget cuts impacting their service. It feeds the mentally ill into the Department of Corrections. It's still cheaper to house the mentally ill in prison than in a state hospital. As money is harder to come by for the DHSS, plans for handling that person, providing services to that person, may not take place. And it's then not unlikely for us to see that person with our system.
Just as it is poor and homeless mentally ill individuals who have the greatest difficulty obtaining the mental health treatment they need, so it is poor and homeless mentally ill individuals who are disproportionately incarcerated. According to the National Resource Center on Homelessness and Mental Illness, the homeless who are mentally ill are twice as likely as other people who are homeless to be arrested or jailed, mostly for misdemeanors. Reproduced in table 1 are figures from the federal Bureau of Justice Statistics (BJS) reflecting the rates of homelessness and unemployment among mentally ill and other prison and jail inmates.
Table 1: Homelessness, Employment, and Sources of Income of Inmates, by Mental Health Status
Mentally Ill Inmates
Mentally Ill Inmates
Mentally Ill Inmates
In Year Before Arrest
At Time of Arrest
Employed in Month Before Arrest
The BJS figures in table 1 suggest higher rates of employment than those arrived at in other surveys. According to the President's New Freedom Commission on Mental Health for example, about one out of every three adults with mental illness are employed. A survey by NAMI of its members revealed that 17 percent of consumers of mental health services were employed part-time and only 14 percent full-time.
The BJS also provides data on the crimes which have sent the mentally ill to prison and jail. According to the BJS, 47.1 percent of mentally ill prisoners confined in state prison and 69.7 percent of mentally ill prisoners in jails committed property, drug, or public order offenses. A higher percentage of mentally ill prisoners committed violent offenses than other offenders (52.9 percent compared to 46.1); similarly, a higher percentage of mentally ill jail inmates committed violent offenses than other inmates (31.3 percent compared to 26.0 percent).
Incarceration is an excessive, unnecessarily costly, and even counterproductive response to low-level nonviolent crimes, particularly when committed by persons who have substance abuse problems and/or are mentally ill. Growing public recognition of the human, social, and financial costs of the country's experiment in mass incarceration has prompted the development of efforts to divert certain low-level offenders from jail and prison. Across the country, drug courts have burgeoned to divert low-level drug offenders into substance abuse treatment programs. Because of the high percentage of mentally ill offenders who also have substance abuse problems, the diversion of drug offenders into treatment programs should help preclude incarceration of some mentally ill offenders.
Although the effort is only nascent, momentum is also developing to divert low-level nonviolent offenders who are mentally ill to mental health treatment rather than jail. There are approximately ninety mental health courts currently operating in twenty-two states. For example, Brooklyn, New York, recently started using a mental health court to divert non-violent mentally ill offenders into mandated treatment programs. In some places, regular criminal courts are able to divert some mentally ill defendants into treatment programs. Connecticut has a program in which its courts can send certain categories of offenders who are deemed to be seriously mentally ill into mental health treatment programs. Although relatively new, these diversion efforts appear to reduce recidivism and are cost-effective as well. A study in Connecticut, undertaken as part of a national study by the federal Substance Abuse and Mental Health Services Administration (SAMHSA), found the average costs of offenders who were diverted into drug treatment programs in Connecticut were about one-third of those who were not.
As this report reveals, for many persons with mental illness, prison can be counter-therapeutic or even "toxic." Nevertheless, we recognize the tragic irony that, for many, prison may also offer significant advantages over liberty. For some mentally ill offenders, prison is the first place they have a chance for treatment. For those who are poor and homeless, given the problems they face in accessing mental health services in the community, prison may offer an opportunity for consistent access to medication and mental health services. Realizing this opportunity depends, of course, on whether the prisons provide the necessary services. Depending on the quality of the facility in which mentally ill offenders are confined, prison may be less dangerous, less chaotic, less troubling than, for example, life as a homeless person on the street or as a misfit living on the fringe of society. "I have been to prison four times: three times for three years, once for two years," 40-year-old E.V. stated, rocking back and forth non-stop as she talked, a year and a half after her release from a women's prison in California. E.V. was shot in the cheek and shoulders in 1986 during a robbery; she claims she was in a coma for two months following this attack, that she began taking drugs afterwards in order to fight off severe depression, and that at night she hears voices - she thinks of the people who shot her - threatening her well-being. Her most recent stints in prison, she said, were the first times she ever had routine access to mental health services. Yet, she stated, if she needed to see a counselor, she'd "have to make like it was an emergency. Get an attitude, conflict. Argue with the C.O.s, stuff like that. Then they'd take you out and give you a ducat [referral] to see someone." Now diagnosed as being borderline developmentally disabled, as well as suffering from acute anxiety, depression, the side-effects of a fifteen-year cocaine addiction, and needing outpatient mental health care, E.V. is an example of the kind of patient, suffering simultaneously from multiple disorders whom the prison system is increasingly being called upon to treat.
IV. WHO ARE THE MENTALLY ILL IN PRISON?
"I am a commander of Star Wars SS. We have been practicing nuclear allimators stronger than the Russians. If I'm killed it's going to burn stars and the world at the same time. If we don't watch it, people will burn and I will go into a different dimension. So I'd like to keep my single cell as long as possible. I write to Berlin, to Red China, they don't send me no package."
- D.O.T., California State Prison, Corcoran.
The mentally ill in prison, as in the world outside prison, suffer from a wide array of mental disorders serious enough to require psychiatric treatment. The symptoms of some prisoners with serious mental illness are subtle, discernable only by clinicians. This is particularly true for prisoners suffering serious depression, who may just appear withdrawn and unsociable to other prisoners and staff. But the serious mental illness of some prisoners is easily identified even by the layman: they rub feces on themselves, stick pencils in their penises, bite chunks of flesh from their bodies, slash themselves, hallucinate, rant and rave, mumble incoherently, stare fixedly at the walls. While many of the mentally ill in prison do not suffer major impairments in their ability to function, some, like the above-quoted prisoner, are so sick they live in a world entirely constructed around their delusions.
Not only is the number of prisoners with mental illness growing, but more persons are being incarcerated whose illnesses fall at the most severe end of the mental illness spectrum. According to Dave Munson, lead psychologist at Washington State's McNeil Island Correctional Center, "the severity of the mental illness of those coming in is increasing. People are no longer going to state hospitals. The prisoners often have no idea how they ended up here." In Oregon, the administrator for counseling and treatment services reported that in the last five years the prison system has begun receiving prisoners who have been in mental health group homes since childhood. Gloria Henry, warden of Valley State Prison for Women, California's largest prison for female prisoners, also points to the severity of the mental conditions of incarcerated women:
I don't know how [some of these women] were sentenced to prison. They have no understanding of why they are in prison. I don't know what purpose it serves. To some degree the services will be limited, because this is a prison, not a state hospital. We're having to adjust and make changes to accommodate mental health - and it's difficult.
Overview of Mental Illness
Mental disorders include a broad range of impairments of thought, mood, and behavior. The degree of impairment can vary dramatically from individual to individual. Also, some individuals with mental illness have periods of relative stability during which symptoms are minimal, interspersed with incidents of psychiatric crisis. Other individuals are acutely ill and dramatically symptomatic for prolonged periods.
In this report, we use the term serious mental illness to refer to diagnosable mental, behavioral, or emotional disorders of sufficient duration to meet diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, (generally referred to as DSM-IV) and that result in substantial interference with or limitations on one or more major life activities. The DSM-IV defines a mental disorder as:
a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g. a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom.
The DSM-IV classification for mental disorders includes serious mental illness (Axis 1) and serious personality disorders (Axis 2). In prisons, the category of serious mental illness is typically limited to such conditions as schizophrenia, serious depression, and bipolar disorder. Schizophrenia is a frightening, complex, difficult, and debilitating disease which may include disordered thinking or speech, delusions (fixed, rigid beliefs that have no basis in reality), hallucinations (hearing or seeing things that are not real), inappropriate emotions, confusion, withdrawal, and inattention to any personal grooming. Among the subtypes of schizophrenia is "paranoid schizophrenia" with characteristics of delusions of persecution and extreme suspiciousness. Even if a person with schizophrenia is described as recovered or in remission, quite likely he or she is neither ill nor well, but will usually have a great deal of difficulty adjusting to life situations, and can be driven over the edge by overwhelming demands. Serious or clinical depression, which can be experienced episodically or chronically, usually includes, among other symptoms, profound feelings of sadness, helplessness, and hopelessness. It can also be accompanied by psychotic features, including hallucinations and/or delusions. Clinical depression, which is far more common among women than men, is a significant suicide risk factor. Bipolar disorder (previously called manic-depressive disorder) is characterized by frequently dramatic mood swings from depressions to mania. During manic phases some people may be psychotic and may experience delusions or hallucinations.
Wholly apart from ensuring adequate mental health treatment, the incarceration of thousands of persons with these illnesses poses extremely difficult management challenges for correctional staff trying to ensure prison safety and security. For example, serious depression puts people at risk of suicide. Persons with schizophrenia may experience prison as a peculiarly frightening, threatening environment that can result in inappropriate behavior including self-harm or violence directed toward staff or other prisoners. Persons with bipolar disorder in a manic phase can be disruptive, quick to anger, provocative, and dangerous.