Treatment or Lack Thereof, of the Mentally Ill While Incarcerated in America, and Alternatives to Prison,Research Paper Example

It has been a well-known fact throughout the world that the United States has the highest rate of imprisonment for adults of all of the developed countries, with more than 2 million adults incarcerated in 2007 (Daniel, 2007.) In addition, because over the last 30 years there has been a policy of de-institutionalization of the mentally ill, a large number of patients with mental health diagnoses have ended up in prison, resulting in these institutions serving as virtual psychiatric hospitals. This paper will discuss the issue of mentally ill inmates, their treatment, their rights, the ability of prisons to adequately provide care for this population, and various programs in the nation that address this problem with varying results.

Statistics that were compiled in 2006 indicate that more than half of inmates in federal prisons and local and state jails suffer from mental illnesses, including more than 700,000 inmates in state prisons, over 78,000 in federal prisons, and nearly 500,000 in local jails (Glaze, 2006.) The statistics defined mental health problems in two ways: either having a recent history of mental problems (within the prior 12 month), or exhibiting symptoms of such a disorder, (as defined by the DSM-IV.) The mental disorder that is the most prevalent among the inmate population are major depression, reported by 23.5% of state prison inmates, 16.0% of federal prison inmates, and 29.7% of local jail inmates (Glaze, 2006.) Mania disorders are experienced by 43.2% of state prison inmates, 35.1% of federal prison inmates, and 54.5% of local jail incarcerated people; finally, psychotic disorders such as schizophrenia are reported to affect 15.4% of state prison inmates, 10.2% of federal prison inmates, and 23.9% of local jail inmates. It should be noted that in addition to mental health problems reported by inmates, a tremendous number of this population are also dually -diagnosed inmates who have both a psychiatric and chemically dependent diagnosis.

The rights of prisoners with mental illnesses have been addressed since the principles of human rights emphasize the vulnerability of prisoners to being abused, so therefore certain protections are required to ensure their rights. The UN Human Rights Committee has defined the obligation of states to preserve and protect the rights of people who have been deprived of their liberty (Mental Health, Human Rights, and US Prisons, 2009.) In particular, prisoners with mental illness are viewed as particularly susceptible to abuses, and are therefore guaranteed the rights of dignity, the right to rehabilitation, the entitlement to the best possible standard of health, and the right to have freedom from torture or cruel, inhumane, or degrading treatment or punishment (Ibid.) Any prison that adopts this framework provides a complete range of mental health services that would include the personnel, resources, and settings necessary to assist the prison or jail population. Monitoring policies and practices would guarantee that security and safety do not compromise treatment for the mentally ill, and staff would not have to choose between what they realize that they should be providing regarding standards of care and best practices of treatment, and what is practical under the circumstances.

In various studies, it becomes clear that inmates with mental illnesses frequently deteriorate while they remain untreated during their wait for a bed in a psychiatric hospital, and frequently commit suicide before they ever receive any mental health treatment (Torrey, 2010.) Nearly half of the inmates who commit suicide are mentally ill, and the “prevalence of mental illness among inmates who attempted suicide was 77%, compared with 15% among inmates in the general jail population” (Ibid.) The reason for this is generally attributed to the fact that these very vulnerable inmates are incarcerated rather than treated for their conditions.

Frequently, inmates, including those with mental illnesses, are placed in solitary confinement, which can be as clinically disruptive as actual physical torture, but in spite of this fact, US prison officials have frequently used this method to punish and control difficult prisoners (Metzner, 2010.) The psychological impact of solitary confinement is particularly detrimental for people with serious mental conditions, especially those with psychotic presentations such as schizophrenia, bipolar disorder, and major depression. The aftermath of this punishment method can involve anxiety, depression, anger, cognitive disturbances, perceptual disruptions, obsessive thoughts, paranoia, and psychosis (Metzner, 2010.) Solitary confinement induces stress, the withdrawal of important social interaction and a lack of structure that can precipitate the symptoms of mental illness. An increase in suicide rates occurs in prison units that utilize isolation frequently, and that situation provokes many mentally ill inmates to require emergency care or hospitalization in a psychiatric institution. In addition, when inmates are segregated, their treatment consists entirely of psychotropic medication and eliminates the individual, group, recreational, and other therapies that are usually available to the inmate.

People associated with correctional institutions that house the mentally ill must be trained to understand that inmates with such conditions frequently have difficulty managing the pressures of being incarcerated as well as adhering to an extremely structured routine. They may respond by demonstrating strange, irritating, or aggressive behavior and tend to experience greater proportions of disciplinary measures than the general prison population. Without adequate training, prison staff tends to react to them the same way they do towards other prisoners who violate rules. These responses do not have the same effect on people with mental conditions, and frequently exacerbate the situation. As a result, there have been many class action cases which have protested the segregation of inmates that have serious mental illness, with the decisions labeling them unconstitutionally cruel because of the tremendous psychological injury it can cause such patients (Metzner, 2010.) In many such cases, a federal ruling has prohibited or significantly limited the use of isolation for mentally ill inmates. The result is that many states, in particular Indiana which was the focus of the original lawsuit, have rushed to make alternative policies and procedures for mentally ill patients who are incarcerated.

Those who have studied the issue of mentally ill people being incarcerated rather than rehabilitated or treated are in agreement that the problem began and worsened after the large numbers of people with mental illnesses were de-institutionalized in the 1980s. The intentions for doing so were based on positive motivations, but the unintended consequences were that massive numbers of people were out on the streets and without any form of follow-up treatment, including psychiatric medications. Many of these former patients became homeless, jailed, or incarcerated in state or federal prisons. The problem has only been compounded because of ongoing cuts in budgets for mental health facilities, a decreasing number of beds in such settings, and federal, state, and local officials appearing to be either oblivious or apathetic to the difficulties that result in fewer cream and options for the mentally ill population.

More than 15 years ago, the US Department of Justice established guidelines that were designed to “manage” mentally ill inmates that were housed in American correctional institutions. The Department acknowledged that while the population of the correctional institutions had risen dramatically, so had the number of mentally ill inmates in every institution. That report anticipated that this segment of the inmate population had the potential to disrupt the management of these institutions, and therefore it was necessary to ensure that they were closely observed in order to avoid management problems (Mentally Ill Inmates: Management of Institutions, 1995.) The tone of this directive clearly contributed to the stigmatization of the mentally ill population, focusing on how to “manage” them as the main priority rather than the provision of treatment that would help in their rehabilitation. Nevertheless, the report did represent a positive step in that it recognized that the mentally ill population needed to have adequate services while in prison. The goals for the program included: recognizing the need for hospitalization of certain mentally ill inmates, but striving to reduce those numbers by “managing and treating” these inmates; providing assessments for inmates when they arrived at the institutions in a timely way, for the purpose of determining the presence and degree of mental impairment and/or suicidal tendencies (Mentally Ill Inmates: Management of Institutions, 1995.)

The report mandated that for every prisoner that was targeted as needing treatment, a treatment plan had to be developed that included defining the mental health needs of the individual, the goals of the treatment, and the maintenance of progress notes on a monthly basis. In addition, significant medical treatment information needed to be added to the inmate’s medical records. The chief psychologist of any correctional institution was required to coordinate the referral or transfer of a mentally ill inmate to the Psychiatric Referral Center or another correctional facility to obtain psychiatric treatment. Some of the programs offered through this directive included intake screening, psychological services, suicide prevention, and use of force and application of restraints for inmates, again suggesting a troubling perception of the behavioral management problems of mentally ill inmates.

Pennsylvania legislators have created a solution to address the problem of prison overcrowding by moving prisoners with mental illnesses into state mental hospitals. This has essentially been done in New York State, when a state psychiatric hospital was shut down several years ago and given over to the state Department of Corrections in order to make it a correctional facility for inmates with serious mental health problems. Therefore, such individuals who had formerly been treated in psychiatric hospitals were now being treated in the same facility that was now regarded as a prison. A more positive development occurred in New York City, when Mayor Michael Bloomberg, an extremely progressive mayor, initiated a significant corrections initiative directed to mentally ill offenders, who constitute approximately 1/3 of New York’s jail population and are more likely than other prisoners to continue antisocial behavior once they are released. The purpose of the program is to give the courts updated information about an inmate’s record and mental health situation so that a judge can determine if the offender should be sent to a treatment program instead of jail (The New York Times, 2013.)

There are several solutions to this problem that have been addressed by knowledgeable psychiatrists and other social scientists. They point to programs in several states, however, which are destructive and only continue to stigmatize the mentally ill inmate population. For example, in Florida, Dade and Broward counties, county jails are being constructed specifically to house inmates that are suffering from chronic and severe mental illness; in Maine, there have been proposals to shut down certain jails, changing them into short-term lockups for people who have mental illnesses (Torrey, 2010.) In another blow to mental illness treatment, Montana has proposed the establishment of a special prison for the mentally ill who are currently being incarcerated with the general prison population. Rather than offering treatment for this population, these proposals simply incarcerate them in more isolated facilities.

The solutions to the problem of mentally ill inmates that provide more potential for success include the use of assisted outpatient treatment, in which mentally ill inmates are released from hospitals, jails, or prisons and are able to receive the treatment required to prevent relapse. Assisted outpatient treatment mandates certain seriously ill people to comply with medication regimes under court order in order to remain out of an institution. Mental health courts should be used to offer offenders the option of either following the treatment plan that includes psychotropic drugs, or going to prison. In these situations, the court essentially becomes responsible for the treatment of the individual, and mandates participation in outpatient and community mental health settings (Torrey, 2010.) Another solution to address the issue of mentally ill inmates can be to conduct unannounced inspections in the prisons of each state every five years or so, identifying the numbers of mentally ill inmates and linking federal monies to that state’s mental health block grants. The states that have the lowest number of mentally ill prisoners incarcerated would be rewarded by receiving the largest grants. In addition, the federal funding system for mentally ill prisoners should be amended, since federal Medicaid, the largest source of money to treat prisoners, does not allow these funds to be allocated to support mentally ill prisoners that are in jail or prison because of mental diseases. This practice has been an incentive for states to “dump” patients from hospitals, regardless of whether they wind up in prison or being homeless. Repealing this restriction would be a tremendous advancement for the care of the mentally ill when they are incarcerated. Finally, laws regarding treatment should be changed so that mental health treatment laws can be established using the need for treatment as a standard instead of the perceived dangerousness of the person. Often, it is when a person is believed to be potentially dangerous that they are able to become involved in the mental health system, rather than when a person is perceived as being mentally ill, but not threatening.

Clearly, there is a tremendous need for mental health treatment for inmates who have been incarcerated, but the states have fallen short, sadly, in recognizing that this population needs services that are different from those needed by the general prison population. It is recommended that each state evaluate its criminal justice system to determine whether or not the practices being employed towards these inmates are in violation of the ban on practices such as solitary confinement for the mentally ill. If the money that each state receives is directly tied to the conditions of the mentally ill inmates in its charge, it would seem to be a powerful incentive to ensure that prisons are utilizing the best possible humane treatments for this population. In addition, more psychiatrists and mental health providers should be on the advisory boards of correctional facilities in order to provide much-needed guidance about the ways to treat mentally ill patients in the humane and rehabilitative fashion.

References:

Daniel, A. (2007). Care of the Mentally Ill in Prisons: Challenges and Solutions. Journal of the American Academy of Psychiatry and the Law , 406-410.

Glaze, L. & Fellner, J. (2006, December 14). Special Report: Mental Health Problems of Prison and Jail Inmate. Retrieved March 3, 2013, from Bureau of Justice Statistics: http://bjs.ojp.usdoj.gov/content/pub/pdf/mhppji.pdf

Mental Illness, Human Rights, and US Prisons. (2009, September 22). Retrieved March 3, 2013, from Human Rights Watch: http://www.hrw.org/news/2009/09/22/mental-illness-human-rights-and-us-prisons

Mentally Ill Inmates: Management of Institutions. (1995, March 31). Retrieved March 3, 2013, from US Department Of Justice, Program Statement: http://www.bop.gov/policy/progstat/5310_013.pdf

Metzner, J. &. (2010). Solitary Confinement and Mental Illness in the US Prisons: A Challenge for Medical Ethics. Journal of the American Academy of Psychiatric Law , 104-108.

More Mentally Ill Persons Are in Jails and Prisons and Hospitals: A Survey of the State. (2010, May). Retrieved March 3, 2013, from Treatment Advocacy Center: dy.pdfhttp://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_stu

The New York Times. (2013, February 1). Editorial. The New York Times , p. A 26.

Torrey, E., Kenn, A., Esslinger, D., Lamb, R. & Pavle, J. (2010, May). More Mentally Ill Persons Are in Jails and Prisons That Hospitals: A Survey of the States. Retrieved March 3, 2013, from Treatment Advocacy Center: http://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_study.pdf