Mental Illness in Prison

Abstract

The mentally ill represent a disproportionately large segment of the prison population in the United States but many receive no treatment and may not be properly screened and diagnosed, leading to higher recidivism rates and worse outcomes. Judicial remedies such as “drug courts,” which divert substance abuse cases into addiction treatment programs, and alternative guilty verdicts are available in some jurisdictions. The problem of insufficient mental health care resources in prison is compounded by an anemic mental health care infrastructure outside prison and the over-policing of the mentally ill.

Overview

In nearly every state, the mentally ill incarcerated population exceeds the population of the largest state-run psychiatric facility, and overall the mentally ill incarcerated population across the country exceeds the institutionalized population by tenfold. Several of the states with the least mental health care access—primarily southern states like Alabama, Texas, and Mississippi—also have the highest incarceration rates. The majority are not incarcerated for violent crimes; a large number (with estimates varying based on differing interpretations of available data) could have avoided arrest if they were under appropriate care for their condition. The right of prisoners to health care, including mental health care, has been affirmed by a number of Supreme Court and circuit court decisions, including Bowring v. Godiva (1977) and Ruiz v. Estelle (1980). Because the United States has a significantly higher per capita incarcerated population as compared with most of the developed world, problems concerning mental illness among the incarcerated are not a minor matter but an important part of the overall picture of mental health in the country.

The mentally ill are disproportionately represented in prisons and jails, and yet these facilities typically provide substantially worse treatment than is available on the outside. Studies consistently affirm the greater prevalence in prison not only of serious mental illnesses—illnesses that could conceivably be implicated in the crimes for which the inmate has been convicted—but also illnesses like agoraphobia, attention-deficit disorder, obsessive-compulsive disorder, and social anxiety, as well as disorders undoubtedly exacerbated by incarceration, including major depression, anxiety and panic disorders, and post-traumatic stress disorder. The relationship between mental illness and prison can be discussed in terms of various points along a timeline in the life of a hypothetical individual: life before arrest, encounter(s) with police, prosecution and encounters with the criminal court system, incarceration, and post-incarceration life. Systemic problems at each of these stages contributes to the prevalence of mental illness among individuals under correctional control. Estimates of the number of people under correctional control who suffer from mental illness vary considerably, but the Department of Justice’s Bureau of Justice Statistics reported in 2006 that at least 45 percent of federal prisoners showed symptoms of serious mental illness, as well as 56 percent of state prisoners and 64 percent of inmates in local jails. Other studies peg these figures much lower, closer to 20 percent. There are many reasons for variations in these estimates, but an important consideration is the impact of incarceration and the conditions experienced therein on the development, exacerbation, or stronger presentation of symptoms of mental illness.

According to the National Alliance on Mental Illness (NAMI), the leading American advocacy group for individuals with mental illness, a crisis of mental health is statistically more likely to result in a police encounter than in the individual obtaining medical assistance. The mishandling of encounters with people in crisis by police resulted in a number of well-publicized shootings in the 2010s. While race was a likely factor in at least some cases, it is also clear that not enough police officers receive sufficient or effective training in dealing with individuals with mental illness. People with untreated severe mental illness represent only about 2 percent of Americans but are the victims of at least 25 percent of fatal police shootings. That there are even this many Americans with untreated severe mental illness represents a significant failure of the institutions surrounding mental health in the United States.

While there would seem to be a clear ethical obligation for police officers and other representatives of the state to take special care in their encounters with individuals with mental illness, whether or not there is a legal obligation to do so, is a matter that came before the Supreme Court in 2015, in the case of City and County of San Francisco v. Sheehan. The case specifically dealt with the legal obligation of responding officers to employ crisis de-escalation methods when they are aware the person or persons they are responding to are mentally ill or exhibiting symptoms of serious mental illness. The Court broke this down into two questions: whether the Americans with Disabilities Act required officers to accommodate individuals with mental illness, a question the Court dismissed because San Francisco had not addressed it in arguments, and whether the officers were entitled to qualified immunity from liability for the injuries suffered in the encounter. While the Court ruled in favor of the officers in qualified immunity, this led to the most important question—whether an obligation exists for police officers to de-escalate encounters with the mentally ill—unresolved.

While “jail” and “prison” are often used interchangeably in casual speech, there is a difference. A jail is maintained by a local or county government, and the inmates are a combination of people awaiting trial (or various pre-trial proceedings), people serving short sentences for nonviolent crimes, and people awaiting transfer to another facility. The accommodations in jails are typically minimal. Mental health care is rarely available, but continuing a prescription may be possible. There are generally limits on how long an inmate is supposed to be held in prison without being transferred to a long-term facility, but bureaucratic slowness and other complications can, in practice, exceed those limits. Prison is a more long-term facility than jail, and it is both more secure and includes more accommodations. Prisons are maintained by state governments or the federal government, or by private sector companies operating on behalf thereof. There are exceptions to these generalities—a small number of states operate both jails and prisons, and the federal government operates a variety of detention centers that do not constitute prisons—and the “cut-off” between short-term jails and long-term prisons is not universally standard. Far more people pass in and out of jail than prison.

Until 1820, confinement in prison was a standard remedy for serious mental illness; the rise of modern psychology and activist movements like the social gospel contributed to concerns over the inhumane treatment of the mentally ill, and efforts were diverted to “cures,” though in the nineteenth century these cures themselves often bordered on abuse. From the nineteenth century until about 1970, though, state and federal authorities alike preferred treatment facilities to incarceration. Since then, the trend has shifted back toward incarceration, if not always in policy than in practice due to insufficient mental health care resources.

Mentally ill individuals spend longer in jail on average than other inmates. The data suggest this is because the mentally ill are more likely to be punished for infractions of jail rules; some may have more trouble understanding, others may find it too difficult to follow the rules, while others may simply attract more attention and get in trouble more frequently as a result. This is especially true in jails where the work culture of the guards and other employees encourages keeping a “close eye” on inmates known to be mentally ill but does not pair that encouragement with the suggestion that such inmates should be assisted, rather than “cracked down on.” Also, in the pre-trial stage, inmates with a mental illness are subject to longer stays while they await evaluation by mental health professionals (such as to establish competency to stand trial). Most jails have wait lists of at least one month for mental health services; in some states, the wait list can be as long as a year, and defendants eventually found innocent or who have the charges against them dropped may be incarcerated pre-trial longer than the sentence they would have served had they been found guilty.

Mentally ill inmates are substantially more likely to commit suicide than other inmates, and the incarceration of the mentally ill is one of the important drivers in rising inmate suicide rates. While these inmates thus face an elevated risk, they receive overall poor treatment while incarcerated. About half of inmates who were medicated for mental health conditions at the time of their admission to prison fail to continue to receive that medication after admission. In some studies, those with schizophrenia are the least likely to continue to receive medication, and lack of treatment continuity is owed partly to insufficient resources and partly to inadequate screening procedures.

Health care priorities in prison are focused on general safety. Physical health conditions that are contagious and present a danger to the inmate population and staff receive a high priority, for instance. Psychiatric medications for chronic mental illness are a significant expense without the same kind of general benefit as antibiotics for preventing outbreaks of disease. Furthermore, while staff has frequent contact with inmates, staff members are not generally well trained in recognizing mental health disorders, the importance of referring an inmate to a professional for treatment, or signs that a medicated inmate may benefit from a change in dosage or medication. Greater overall medication usage within the prison also presents complications in the form of their attendant side effects or other special considerations, such as food interactions with certain medications.

One of the most important issues in prison reform is recidivism—the phenomenon of a released inmate being convicted and returning to prison. Recidivism rates are a common metric used to assess the efficacy of various criminal justice measures; if the criminal justice system is intended to serve any purpose other than simply punishing those who commit crimes, one of its chief purposes must be to reduce the frequency of crime, in part through the rehabilitation of offenders such that they do not re-offend. Inmates with mental illness have a higher rate of recidivism than those without; more than three times higher in some studies. Among inmates with mental illness, those who receive a diagnosis are somewhat less likely to re-offend than those who do not. Even the limited mental health care available in prison makes a measurable difference on those who receive it.

Further Insights

The prevalence of mental illness in prison was exacerbated by changes in the early 1980s to federal law and funding by President Ronald Reagan and similar changes enacted by state legislatures, which combined to severely reduce the capacity in mental health treatment centers throughout the country. In 1967, as California governor, Reagan had abolished the involuntary hospitalization of patients with mental illness with the Lanterman-Petris-Short Act, and in so doing, cut the population of the state’s treatment center population by more than half. The act sought to abolish involuntary hospitalization (“being committed”) and forced treatment, a move supported by many in the mental health field, but in combination with reduced funding and an absence of adequate policies and infrastructure for dealing with a substantial population of people with disabling mental illnesses, it simply meant more people did not receive any treatment and often had nowhere to live. As president, Reagan similarly discontinued federal funding of community mental health treatment centers in 1981. Subsequent studies found that, for instance, over a quarter of the mental health patients discharged from one representative treatment center had become homeless.

Over the course of the 1980s, even as rising violent crime was a topic of ongoing political discourse, the homeless population grew enormously. Veterans from the recent Vietnam War “fell through the cracks” of what had previously been a robust support system. The spike in homelessness in the 1980s is one from which the country has still not recovered; once a phenomenon related to America’s boom and bust economic cycle, urban homelessness had become a norm. People who could have functioned in society with the help of diagnosis and treatment faced greater and greater difficulty in doing so—especially as health insurance costs skyrocketed, the number of Americans not receiving insurance from an employer increased, and the number of insurance programs with robust mental health coverage decreased.

Issues

A number of initiatives have addressed the problem of mental illness in prison and jail. NAMI, pointing out that 83 percent of jail inmates lack access to mental health treatment, founded the Stepping Up Initiative in collaboration with the Council of State Governments Justice Center, the American Psychiatric Foundation, and various law enforcement groups and mental health or substance abuse organizations. The Stepping Up Initiative seeks to raise awareness of mental health issues with regards to jail inmates, encouraging reforms that reduce the jailing of people with mental illness by, for instance, de-escalating crises during police encounters in order to avoid arrests or referring individuals to treatment and other resources.

Another way to reduce the number of mentally ill people who become incarcerated is through diversion programs, which are designed for certain kinds of offenders as an alternative to the criminal trial procedure. Drug courts, for addicts, are the most familiar form, but some jurisdictions use mental health courts as well. However, the most effective form of diversion involving defendants with mentally illness is “pre-booking”—that is, processes and procedures that reduce the likelihood of mentally ill people being charged with crimes when treatment for their condition is a better remedy. The primary obstacle to pre-booking diversion is a lack of sufficient public mental health resources; a large number of defendants who would more ideally be given treatment wind up incarcerated instead, exacerbating rather than remediating the problem, at significant public expense.

A verdict available in some jurisdictions, in applicable cases, is “guilty but mentally ill” (GBMI). In some jurisdictions, GBMI is available as an alternative when the defendant does not meet the requirements for a “not guilty by reason of insanity” (NGRI) plea. While an NGRI verdict results in the defendant being sentenced to a treatment center rather than a prison, a defendant who is ruled to be GBMI is sentenced to prison, like other defendants, but is prescribed mental health care appropriate to his or her condition. In practice, studies suggest few GBMI inmates actually receive such care because of insufficient resources. A judge or jury can mandate mental health care, yes, but if the prison simply lacks the resources to offer such care, or maintains a lengthy wait list for receiving such care, most inmates have little recourse.

Terms & Concepts

Correctional Control: Incarceration in prison is just one period during a larger period of time during which an individual is under correctional control, meaning that they are subject to the corrections system of the state or federal government, which includes not only time spent incarcerated (whether serving a sentence or awaiting trial) but time spent on parole or probation.

Diversion Programs: Criminal justice programs designed to provide alternatives to trial or prison for certain types of offenders—often meaning addicts, juveniles or young offenders, the mentally ill, and nonviolent offenders.

Inpatient Treatment: Medical treatment administered while the patient remains in a facility providing treatment, with 24-hour care available; this may be short-term, as with a patient admitted for surgery from which some professionally monitored recovery time is necessary, or long-term, as with month-long drug addiction treatment or chronic serious health problems, whether physical or psychiatric.

Institutionalization: In this context, the practice of “committing” patients with mental illness—that is, admitting them for inpatient treatment on a long-term or indefinite basis, whether voluntarily or involuntarily. Historically, many who were institutionalized received little to no treatment as such and were de facto incarcerated.

Mental Health: Encompasses a patient’s psychological and emotional well-being, including conditions with an underlying physical or physiological cause or exacerbant.

Mental Illness: Also called a mental disorder, psychiatric disorder, or mental health condition; a condition impacting a person’s thinking or mood, especially such conditions with sufficient impact that the person’s ability to function or interact with others is affected. Mental illness may be “situational,” in that it is a response to something the person has experienced (such as stress from an emotionally abusive workplace environment, or postpartum depression), or may be caused primarily by biochemical processes; the causes of many mental illnesses are poorly understood, and individuals vary in their experiences of diagnosed conditions.

Treatment Center: A treatment center or treatment facility is a dedicated facility for the treatment of mental health or drug addiction needs, especially inpatient treatment (though outpatient services may also be offered).

Bibliography

Coffey, P. (2012). Insights into working with mentally ill offenders in corrections. Corrections Today, 74(2), 52–55. Retrieved January 1, 2019 from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=80131963&site=ehost-live

Daquin, J. C., & Daigle, L. E. (2018). Mental disorder and victimisation in prison: Examining the role of mental health treatment. Criminal Behaviour & Mental Health, 28(2), 141–151. Retrieved September 15, 2018, from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=128929322&site=ehost-live

Matejkowski, J., & Ostermann, M. (2015). Serious mental illness, criminal risk, parole supervision, and recidivism: Testing of conditional effects. Law & Human Behavior, 39(1), 75–86. Retrieved September 15, 2018, from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=100888503&site=ehost-live

Morgan, R. D., Fisher, W. H., Duan, N., Mandracchia, J. T., & Murray, D. (2010). Prevalence of criminal thinking among state prison inmates with serious mental illness. Law & Human Behavior, 34(4), 324–336. Retrieved September 15, 2018, from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=52227268&site=ehost-live

Stoliker, B. E., & Varanese, J. (2017). Spending the golden years behind bars: Predictors of mental health issues among geriatric prisoners. Victims & Offenders, 12(5), 718–740. Retrieved September 15, 2018, from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=123351605&site=ehost-live

Theurer, G., & Lovell, D. (2008). Recidivism of offenders with mental illness released from prison to an intensive community treatment program. Journal of Offender Rehabilitation, 47(4), 385–406. Retrieved September 15, 2018, from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=34793071&site=ehost-live

The treatment of persons with mental illness in prisons and jails: A state survey. (2016). Corrections Forum, 25(1), 30–36. Retrieved September 15, 2018, from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=112923704&site=ehost-live

Wilson, A. B., Farkas, K., Ishler, K. J., Gearhart, M., Morgan, R., & Ashe, M. (2014). Criminal thinking styles among people with serious mental illness in jail. Law & Human Behavior, 38(6), 592–601. Retrieved January 1, 2019 from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=99987587&site=ehost-live

Suggested Reading

Byng, R., Howerton, A., Owens, C. V., & Campbell, J. (2015). Pathways to suicide attempts among male offenders: The role of agency. Sociology of Health & Illness, 37(6), 936–951. Retrieved January 1, 2019 from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=108610638&site=ehost-live

Cox, C., & Marland, H. (2018). Broken minds and beaten bodies: Cultures of harm and the management of mental illness in mid- to late nineteenth-century English and Irish prisons. Social History of Medicine, 31(4), 688–710. Retrieved January 1, 2019 from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=133366168&site=ehost-live

Forrester, A., Exworthy, T., Chao, O., Slade, K., & Parrott, J. (2013). Influencing the care pathway for prisoners with acute mental illness. Criminal Behaviour & Mental Health, 23(3), 217–226. Retrieved September 15, 2018, from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=88931405&site=ehost-live

Golden, D. (2013). The Federal Bureau of Prisons: Willfully ignorant or maliciously unlawful? Michigan Journal of Race & Law, 18(2), 275–294. Retrieved September 15, 2018, from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=88004257&site=ehost-live

Knight, B., Coid, J., & Ullrich, S. (2017). Non-suicidal self-injury in UK prisoners. International Journal of Forensic Mental Health, 16(2), 172–182. Retrieved September 15, 2018, from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=122926478&site=ehost-live