Transcript Prison Mental Illness: America's jails and prisons house more mentally ill individuals than all of the Nation's psychiatric hospitals combined.

Prison Mental Illness:
America's jails and prisons house more mentally ill individuals than all of the Nation's psychiatric hospitals
combined. (US Congress)
A National Crisis,
A Moral Outrage
Understanding the Problem:
A History
Q u ic k T im e ™ a n d a
decom pr e ssor
a r e n e e d e d t o s e e t h is p ic t u r e .
During the 1950-60s a new approach was taken to the treatment of mental illness. Called deinstitutionalization, politicians
sought to close state psychiatric hospitals and replace them with community-based treatment centers.
Intended as a humane, liberating and progressive alternative to indefinite hospitalization, deinstitutionalization did not
work out as planned. As the majority of state psychiatric hospitals were shut down, mental health need continued to grow
and the severely mentally ill were left to fend for themselves. Appropriate resources were not allocated to outpatient centers
whose clinicians were unable to adequately serve their overflowing caseloads. By the 70s, a new trend began to emerge:
transinstitutionalization, “the transfer of institutional populations from hospitals to jails, nursing homes, and shelters.”*
Unable to function in society, former psychiatric patients as well as the next generation of mentally ill Americans, were
landing in prison at unprecedented rates.
Furthermore, during the 1980s and 1990s, tougher sentencing, especially for drugs crimes, began to emerge. This has
specifically affected the mentally ill because of the frequent comorbidity of mental illness and substance abuse. According to
the Department of Justice, 45.5% of all American inmates suffer from both issues.
Statistics: The Scope of the Problem
In Pennsylvania...
•In 2007, the Dept. of Correction reported 21.5 %
• America imprisons 1 in 100 of its adult citizens,
giving it the world’s highest rate of incarceration.
(Pew)
• Totaled together, in 2005 there were at least
1,185,500 (55% of the prison population)
mentally ill Americans incarcerated according to
DOJ’s conservative estimate. *
• Of these, 6% of the prison population can be
classified as “severely mentally ill” with illnesses
such as schizophrenia, major depression, and
bipolar disorder. (National Alliance on Mental
Illness)
• About 75% of all inmates who had a mental
of inmates were on the Mental Health Roster,
meaning they are mentally ill and in treatment. 2.8%
were designated as “severely” mentally ill. This
number only represents people whom the DOC has
allowed onto the roster and thus designated as MI,
and is likely an underestimate.
•For the 11,081 people on both rosters, the DOC
employed 170 “psychology staff”. A ratio of 1 staff
member to over 65 inmates. (DOC)
•For those correctional officers and supervisors
assigned to special needs units, the state requires a
two-day training. (PBS)
* 705,600 state prisoners (56%), 78,800 federal prisoners (45%),
479,900 jail inmates (64%)
What’s Wrong with Incarcerating the Mentally Ill?
The mentally ill face innumerable obstacles in every facet of society. It is harder for them to find and maintain employment, housing and
acceptance in a society whose rules are sometimes a foreign language. In court, they are less able to assist in their own defense. In prison,
a terrifying experience for anyone, the mentally ill are less able to cope with the tense, violent atmosphere and many rules than their peers.
Fact: According to the DOJ, mentally ill
inmates in state prisons serve on average 15
months longer than other inmates for
infractions committed while in psychiatric
crisis. In addition, they face parole boards
already reluctant to release them into
communities which inevitably lack the
services they need.(PBS/DOJ)
Fact: Inmates with mental illness are
denied justice at every juncture.
Fact: Inmates with mental illness are more
likely to be sexually victimized while in
prison than their neurotypical peers. (US
Congress)
Fact:
The
mentally
ill
are
disproportionately represented among
prisoners in segregation. A result of poor
behavioral control, MI inmates land in
solitary confinement where they are held in a
small cell with no human contact for up to
23 hours per day. Psychiatric research has
shown the effects of solitary to be
devastating for the healthiest of people; for
individuals with MI, solitary confinement is
akin to torture.
Incarcerating the severely mentally ill does
not make anyone safer. The behavior of
severely ill inmates endangers guards,
other inmates and of course, the individuals
themselves.
Ultimately, the majority of mentally ill
inmates are released back into
communities more sick and more
dangerous than before.
Fact: Prisons are not psychiatric
hospitals. Prison mental health care is
FACT: America's jails and prisons
house more mentally ill individuals
than all of the Nation's psychiatric
hospitals combined. (US Congress)
FACT: Prison is a useless and
inhumane alternative to
treatment for the mentally ill.
severely limited by lack of finances and
professionals willing to work in such a
challenging setting. Prisons are simply illequipped to handle the complex needs of
the mentally ill responsibly, ethically and
humanely..
Fact: Mentally ill inmates are often unable
to cope with and understand the myriad
prison rules. They incur more disciplinary
infractions than their peers; in fact 58% of all
state prisoners with a diagnosed MI had
been charged with rule violations. In effect,
they are punished for their illnesses.
Incarcerating the Mentally Ill:
Legal Issues and Standards
We know that prison in general, and solitary confinement specifically, are not effective responses to
crime committed by the mentally ill. We know that the conditions created by this atavistic system are
backwards and inhumane. The next question is, by what laws are they regulated?
There are several legal standards relevant to the treatment of mentally inmates:
The 8th Amendment of the US Constitution:
Also known as the “Cruel and Unusual Punishment
Clause”, this fundamental Constitutional law protects an
individual’s right to be free from “the wanton infliction of
pain”. Lawyers have argued that treatment such as the
use of prolonged isolation in solitary confinement on
mentally inmates constitutes constitutes cruel and
unusual punishment.
Unfortunately, recent legislation (PLRA) creating
administrative roadblocks, unsympathetic juries and
judges and lack of access to the court system has made
it difficult for inmates to argue their 8th Amendment
cases.
Due Process: Due Process is the legal guarantee (5th/14th Am.) that government will
respect a person’s Constitutional right to liberty The Supreme Court has found that this
standard applies to prisoners in situations where the length of sentence may change (a
“liberty interest”). According to Due Process, inmates have a right to be heard in front of an
impartial decision maker with limited representation. This is extremely important for MI
inmates whose frequent behavioral transgressions may result in lengthened sentences.
Unfortunately, adherence to Due Process behind prison walls is cursory.
Americans with Disabilities Act (ADA):
The most frequently cited federal law in
prison MH cases, the ADA ensures equal
access for people with disabilities.
Disability law firms have sued prison
systems successfully contending that they
fail to adequately accommodate and
respect MI inmates’ legal right to equal
access on the basis of psychiatric disability.
International Covenant on Civil and Political
Rights (Torture Convention):
This piece of international law was ratified by the
US in 1992, giving it the same legal standing as
federal statutory law. Its language prohibits
“torture and other cruel, inhuman, or degrading
treatment or punishment.” Unfortunately,
caveats added by the US have made these laws
virtually unenforceable. ICCPR has not been
used successfully in an American prison abuse
suit.
Incarcerating the Mentally Ill:Professional
Incarcerating the mentally ill:
Standards
Professional Standards
Providing mental health treatment in prison is a challenge. From lack of resources to understaffing, professionals face many
obstacles in treating their patients. Psychologists, physicians, social workers and nurses all have professional standards
which they must uphold. An ethical dilemma arises when the realities of practicing in a prison conflict with the standards and
expectations of a profession. For example, a prison psychologist has dual responsibilities: he or she must use his/her
professional expertise to help prison officials manage an inmate while also maintaining the patient's confidentiality, an
expectation dictated by the American Psychological Association. Below are some of the issues professionals face in trying to
provide quality treatment to mentally ill inmates:
Inadequate Screening/Monitoring: Despite
screening requirements upon admittance, many
mentally ill prisoners are not identified and thus
left untreated. This due to inadequate screening
methods, unqualified staff and disorganization.
Lack of Treatment Plan: Outdated, psychotropic
medication is frequently utilized as the sole
treatment for prisoners with mental illness. In
addition, it is difficult to ensure that proper
administration and follow-up care occur.
Lack of Confidentiality: In a prison setting,
confidentiality is complicated by lack of private
facilities for therapy sessions and staff apathy
about importance of privacy issues. Instead,
therapy sessions and healthcare consultations
are often held through the patient's cell door. This
lack of privacy causes the patient to withhold
important personal information.
Diagnoses of Malingering: Prisoners' mental
health complaints are often dismissed as
malingering, or “faking it” for attention or simply to
be manipulative.
Staffing: Mentally ill prisoners frequently lack
access to the necessary range of various mental
health professionals required for comprehensive
treatment. Prisons often hire under-qualified staff
as a means to lower costs; however, this staffing
deficiency translates to inadequate healthcare and
treatment options for prisoners.
Lack of Access: According to the APA, “[t]imely
and effective access to mental health treatment is
the hallmark of adequate mental health care.” 345
However, administrative regulations often prevent
timely access to treatment forcing inmates to wait
as long as several months just for their request to
be processed
Women, Prison and Mental Illness
It is widely known that female prison population is vastly different from the male counterpart. Incarcerated women tend to be
more mentally ill, drug-addicted, abused and disadvantaged than male inmates. The crimes they commit are less violent,
most frequently related to drug possession and sale. The majority of female violent crime is committed in response to
abuse. Despite these differences and their critical implications, women are incarcerated in a system designed for males,
which offers them fewer resources and less treatment than their male counterparts because of their minority presence.
Female inmates attempt suicide five
times more often than their female
counterparts in the community and
twice as often as their incarcerated
male counterparts. (SHMAI)
More than half of all
female prisoners are
serving time for a
drug offense. (DOJ)
Female inmates in jails and
prisons are less likely than
men to receive the services
they need. (Northwestern)
In 2004 the DOJ reported 877
cases of substantiated sexual
abuse by guards against female
prisoners. This number only
represents cases that were
reported. Most are not.
Pre-prison sexual/physical
abuse statistics for
women range from 68%
(DOJ), to 90% (NY DOC).
An estimated 73% of females in
State prisons, compared to 55%
of male inmates, had a mental
health problem. (DOJ)
Nearly two-thirds of
the women serving a
sentence for a violent
crime had victimized a
relative, intimate, or
someone else they
knew.
Conclusions: What Needs to Be Done
The prison mental health crisis is cyclical. Lack of safe and effective alternatives leave judges little choice but to sentence these individuals to prison, a toxic
environment but perhaps the only in which they are likely to receive treatment. Upon release, mentally ill inmates have few places to turn.
As one Ohio inmate, Sigmond Clark, put it:
"Six days with $75 in my pocket. Fare the best way you can, man. We done took 12 years out of your life, and you're mentally ill … do what you
can for yourself.
According to PBS, “when Clark's $75 ran out six days after his release, he violated his parole by stealing a woman's purse. He was given a two-year mandatory
sentence and was returned to Ohio corrections to continue his original sentence of 11 to 40 years.”
The Consensus Project, run by the Council of State Governments, released these recommendations to
improve services for released mentally ill inmates:
1. Implement an evidence-based practices into
public mental health.
2. Integration of Services: integrate different
services and fields of medicine to provide
comprehensive care.
3. Co-Occurring Disorders: implement a
holistic, integrated approach to treatment of
persons with co-occurring mental illness
and substance abuse disorders
4. Housing: Make affordable, coordinated
public housing with array of options to meet
different levels of need.
5. Workforce: Plan to increase the supply of
and to train skilled mental health providers.
6. Consumer and Family Member Involvement:
Involve participants and their families
throughout the process to ensure all that
people with MI are accessing all benefits for
which they are eligible.
7. Cultural Competency: employ minorities and
develop outreach programs to make services
available to members of minority communities.
8. Accountability: Use customer evaluations and
utilize performance measures in budgeting,
contracting, and managing mental health
services.
9. Advocacy: Create public support for the
necessary investment in these services.
Questions for the future
Questions:Professional standards exist for practitioners of medicine and psychology to protect the dignity, safety and comfort of their clients. To be in accordance with
these expectations, are there certain assignments or circumstances in which professionals cannot work?What basic standards must be met to remain in keeping with
professional ethics (for psychologists, nurses and physicians)?In circumstances where resources such as supplies, medicine, and staff needed to maintain standardof-care treatment are limited, in what ways are the professional's responsibility to industry standards and guidelines adjusted?To what extent is a professional
expected to follow up with and ensure that the treatment he/she prescribes is made available to the patient? Does this standard change for the professional who
practices under the auspices of a non-medical institution such as a prison?In treating institutionalized persons whose situations may prevent optimal or standard-ofcare treatment, what is expected of the professional? Should she ALWAYS treat/evaluate the inmate to the best of his/her ability? Are there any situations in which a
professional's responsibility to ethical standards overrides the imperative to offer medical/psychological attention to someone in his/her care?If the outcome of
providing professional care/assessment may result in an ethical violation (such as participation in an execution or torture) or in a change of circumstances that would
be medically/psychologically contraindicated (such as the placement of a person with psychosis in solitary confinement), what is expected of the professional? Should
he or she withhold services? To what extent is s/he considered culpable: professionally, ethically and legally, for adverse (medical and/or ethical) outcomes of
care?What can be done to better allow professionals to balance the competing demands of their profession with the reality of prison practice?To whom is the
professional's responsibility greater, his/her employer or to those in his/her care? What is expected of the practitioner in situations where those needs conflict?Do
professional organizations have a responsibility to lobby for changes in law or policy that reflect the outcomes of research within their field?
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Bibliography:
Professional Standards/orgs:
http://www.psych.org/MainMenu/PsychiatricPractice/Ethics/ResourcesStandards.aspxhttp://www.bazelon.org/index.htmlBazelon Center for Mental Health Law
http://www.apa.org/ethics/code1992.html
http://www.bazelon.org/issues/criminalization/factsheets/pdfs/index.htmBazelon Center for Mental Health Law: Fact Sheet on Criminalization of MI
Prisonershttp://www.mhasp.org/advocacy/systems.htmlMental Health Association of Southern
Pennsylvaniahttp://www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay.cfm&ContentID=76792NAMI's official stance regarding
criminalization of the mentally ill; includes official statements regarding access to treatment while incarcerated, and training/education of service personnel.
Stuart Grassian, MD, Solitary Confinement Report:
http://docs.google.com/gview?a=v&q=cache:Yhm87kCsl7oJ:www.prisoncommission.org/statements/grassian_stuart_long.pdf+stuart+grassian+report&hl=en&gl=us
“Hellhole”, New Yorker article about solitary by Atul Gawande:
http://www.newyorker.com/reporting/2009/03/30/090330fa_fact_gawande
Legal Standards:http://www.law.harvard.edu/students/orgs/crcl/vol41_2/fellner.pdfA Harvard Law document about mental illness and prison
ruleshttp://www.stanford.edu/group/psylawseminar/Ethics.htm
http://www.abanet.org/crimjust/standards/prisoners_status.html
STATE/FED/STATS:
http://www.pacode.com/secure/data/049/chapter41/s41.61.htmlhttp://www.hrw.org/reports/2003/usa1003/index.htmAn extremely detailed and throroughly rssearched report on the mentally ill
in US prisons.DOJ:http://ojp.usdoj.gov/bjs/pub/ascii/mhppji.txthttp://ojp.usdoj.gov/bjs/pub/press/mhppjipr.htmhttp://suicideandmentalhealthassociationinternational.org/preventionprison.html
Multimedia:
www.jennackerman.com:Beautiful prison photography, focus on MIwww.pbs.org/wgbh/pages/frontline/shows/asylumsAMAZING documentary on MI in prison, great links and resources.t