The enormous growth in the national prison population has intensified the problems presented by the needs of mentally ill inmates. A report released by Human Rights Watch late last year—“Ill-Equipped: U.S. Prisons and Offenders with Mental Illness”—examines in depth the situation of the adult mentally ill in state and federal prisons. The report is long and well-researched, blending material from legal documents, court records, academic studies, site visits, interviews and letters.
Originally established in the 1970s to monitor compliance with the human rights provisions of the Helsinki Accords, Human Rights Watch has developed into a more broadly focused international observer of government policies and practices affecting human rights throughout the world, with its reports, such as this one, based on intensive fact-finding research. Behind its examination of this aspect of U.S. prisons is the understanding that “because prisons operate in secret, for the most part, it is important for the public to have access to as much material as possible.”
The report is a tool for focusing attention on the situation. It offers recommendations for change, but its main value possibly lies in the depth and thoroughness of its research, which provides detached examination of the range of problems presented by mentally ill prisoners. The report provides a detailed look at the situation behind the numbers that have been compiled in numerous other reports.
Prisoners have rates of mental illness two to four times higher than those occurring in the general population, and according to this report, there are three times more mentally ill people in U.S. prisons than in mental health hospitals. Between two and three hundred thousand people incarcerated in federal and state prisons suffer from severe mental illnesses such as schizophrenia or bipolar disorder. On any given day, about 70,000 are psychotic. These numbers represent a severe crisis for prison systems throughout the country.
The report discusses two main reasons why the numbers have risen to a crisis level. First, as a result of the deinstitutionalization movement of the 1960s, many mental health hospitals were closed, but community mental health systems which were envisioned as taking the place of hospitals did not develop sufficiently. Many mentally ill—particularly the poor—are now without access to help. Over the same time, politically-generated “tough on crime” attitudes throughout the country have given rise to criminal codes under which more people are being incarcerated for a wider range of crimes for longer periods.
A term—criminalization of the mentally ill—has become current. It encompasses the ways in which the mentally ill who do not have access to adequate support and treatment can become caught in the justice system when their behavior deteriorates to the point where they commit a criminal offense—often low-level street disorder types of crime, but sometimes violent and more destructive acts. By default, correctional systems have become the greatest providers of treatment for the mentally ill in the country. But correctional systems are very poorly designed to be treatment providers.
The report only glances at how criminal codes handle the factor of mental illness, and only by implication does it look at sentencing practices. Its focus is the actual administration of prison systems in which, rightly or wrongly, there are many mentally ill prisoners. It provides an overview of the medical and administrative complexities presented by mentally ill inmates, with numerous examples and case studies garnered from prison, court and medical records, academic research, interviews, and letters. One aspect of the investigation encompassed review of litigation involving various state prison systems. Investigators also solicited letters from inmates. Some of these are appended to each chapter. The authors did not edit the letters, choosing instead to present the individual voices of these prisoners directly. The physical and mental desperation of the some of inmate voices as they describe their illnesses and prison experiences is searing.
As recently as two decades ago, there was little mental health care available in prisons, but there were also many fewer prisoners with mental illness. As the numbers have risen, prison systems have responded with policies for providing for this sub-population of the incarcerated but, as the report notes, “Many prison systems have good policies on paper, but implementation can lag far behind.” Almost all systems now struggle to structure and fund care for these inmates.
Care for mentally ill prisoners is expensive, adding significantly to the generally high costs of prison systems. Because of the way costs associated for caring for the mentally ill are dispersed throughout correctional budgets, as well as the budgets of other state agencies, it is hard to calculate totals, but the authors of this study cite figures from the Pennsylvania correctional system. In Pennsylvania, the average cost to incarcerate one inmate per day is given as $80. For a mentally ill inmate, the added cost of mental health services, medication and additional correctional staff raise this to a daily average cost of $140.The mentally ill have, by definition, limited skill in coping with daily reality. They are at an even greater disadvantage under the physical conditions and routines which characterize many prisons—the crowding, the noise, the lack of medical attention. They are vulnerable to exploitation and abuse. Because, due to their illnesses, they often can’t internalize prison behavior rules, they are often in violation and they become subject to disciplinary measures, further undermining their stability.
Among the greatest problems involved in managing the mentally ill prisons is that correctional staffing is rarely at an adequate level to supervise and care for these prisoners. The report analyzes the complexities presented by this lack of human resources. Few systems have enough correctional guards and mental health care professionals available. In addition, correctional officers in many state prisons have never received training in working with the mentally ill. Correctional staff are actually present with prisoners more than medical or other mental health care personnel. They become more alert to the behavior patterns of individual prisoners but are often not trained to handle this behavior—which can be dangerous and frightening. The stress and fear can lead to abuses, including excessive use of force to control inmate behavior.
There are also usually too few mental health care professionals available to treat prisoners. Therapy sessions can sometimes be little more than a roll-call walk through a cell block by a counselor. Therapist positions may be filled by poorly qualified personnel, and prison systems easily fall into depending on medication alone to control these inmates. In addition, turnover among correctional staff and mental health care staff can be destabilizing for the mentally ill and can also lead to problems with continuity of care.
The administration of mental health care in prisons is also hampered by the lack of specialized facilities to provide hospital care for the most seriously ill; poor screening; inadequate data management; and poor tracking—especially in larger systems. In the regular movement and transfer of prisoners which typify many larger systems, continuity of care becomes an immense problem. Moreover, because in general the prison population comprises primarily young adults in the age range in which chronic mental illness begins to appear, many prisoners begin to develop signs of sickness after they are already incarcerated—and are not readily diagnosed.
Prison administration—the structured routines and discipline necessary for safety and security, particularly in larger prisons—often work against the stability of the mentally ill, causing a deterioration in behavior rather than more conforming behavior. For example, prison scheduling—necessary to manage the general inmate population—can impede timely access to medical attention for mentally ill inmates: “Some prisons require prisoners to take medication in the early evening that should be taken just before a patient goes to sleep [causing the patient] to become increasingly anxious before the medication takes effect.”
Medication is too often the only assistance available. The Human Rights Watch investigators found problems in this area too. Budget constraints sometimes force the use of older, less effective drugs, and in some systems the prescribing physicians may have had almost no contact with the inmate. In some systems, non-medically trained guards are the ones to distribute the medication.
The report focuses in particular on the widespread use of segregation—isolation as a disciplinary measure used to control inmates who have violated prison rules. Isolating prisoners who have become disruptive or have otherwise broken prison regulations in some form of solitary confinement is a common practice. The report criticizes it as being overused in general in U.S. prisons and particularly overused with mentally ill inmates.
Because the mentally ill often act out, they are difficult to manage and are likely to incur this type of disciplinary measure, but solitary confinement inevitably worsens mental illness. Segregation or isolation cells are often used because there is no alternative: prisons lack sub-acute care facilities. When held in isolation under particularly restrictive conditions, these inmates are also more prone to self-destructive acts—self-mutilation and suicide.
The lack of proper care begins a cycle—disruptive behavior, management by isolation, worsening behavior, hospital confinement until stabilized and then a return to inadequate care. As the report comments, “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.”
Some of the most troubling incidents described in the Human Rights Watch report involve the placement of mentally ill prisoners in segregation. It is in this area that the investigators found the most abuses—prisoners in some systems being held for long periods in isolation cells, sometimes naked, sometimes surrounded by their own waste.
This is the area in which the report is most strongly critical of the U.S. prison system as a whole. The evidence is clear that some prisons are in violation of international covenants on prisoners to which the U.S. is a signatory.
Mentally ill prisoners can also be caught in a cycle of recidivism, in which they return again and again to prison. The Human Rights Watch report touches briefly on the general lack of pre-release planning for these inmates and the absence of support beyond the prison for the mentally ill. Newly released prisoners often lack money, housing, employment and access to medical care. This makes reentry difficult for all prisoners, but for the mentally ill the situation can be disastrous. Gaps in treatment and suspension of medication can result in a resurgence of the illness—and behavior that leads to another arrest.
The report concludes with a review of the pertinent legal standards, both under U.S. law and international covenants, noting that advances and improvements in prison conditions have often been the result of litigation.
The report presents extensive, specific lists of recommendations for action by different entities, including the U.S. Congress, other public officials and community leaders, and correctional administrators. Among these is passage of an already-drafted piece of legislation, “The Mentally Ill Offender Treatment and Crime Reduction Act,” which could serve as a catalyst for reform throughout the country. Many of the recommendations would involve commitment of more resources, and they would entail deep structural changes within prison systems.
What emerges again and again in the Human Rights Watch report is that with the mentally ill, prison systems are being constrained to handle problems beyond the scope of their resources—problems that by their very nature will become worse, not better, under the conditions of mass imprisonment. The report is not an unrealistic plea for the release of mentally ill prisoners who have been convicted of crimes, but it does advocate for some specific reforms. Perhaps more importantly, it provides a clear, deep focus on the daily realities of operating large prison systems, particularly with regard to this most vulnerable type of inmate.
Antonia Moras is editor of the Alaska Justice Forum. The report discussed in this article, “Ill-Equipped: U.S. Prisons and Offenders with Mental Illness,” can be found on the Human Rights Watch web site at www.hrw.org.