INTRODUCTION: PUBLIC MENTAL HEALTH POLICY I. THE COMMUNITY MENTAL HEALTH MODEL II. ALTERNATIVES TO INCARCERATION III. THE COMMUNITY MENTAL HEALTH MODEL IN CORRECTIONS A. A Definition of Mental Health in Corrections B. The Requisite Components of Mental Health in Corrections C. Intermediate Care: A Crucial Component of Mental Health Services D. Suicide and Self-Harm E. A Note About Trauma IV. SOME ISSUES UNIQUE TO CORRECTIONAL SETTINGS A. Isolative Confinement and Supermax Security B. Medications and Medication-over-Objection C. The Disturbed/Disruptive Prisoner D. Use of Force E. Therapeutic Cubicles F. Malingering V. SOME GUIDING PRINCIPLES CONCLUSION INTRODUCTION: PUBLIC MENTAL HEALTH POLICY
Some social policies are carefully designed, vigorously debated, and then put into practice through legislation. Medicare is an example; the federal law culminates public debate and establishes a strong social policy regarding medical care for seniors. Other policies are not as clearly formulated and ultimately prove foolhardy, but they are similarly effected through legislation. The imprisonment binge of the past several decades is an example. Legislation, presumably mirroring public opinion, shapes ever longer prison sentences for a growing number of charges. The designers of that social policy, however, failed to see the long range costs in higher recidivism rates, decimation of inner city communities, and mandated medical care for a huge population of older prisoners. Then there are social policies that are never actually articulated, are not guided by specific legislation, and seem to have no champions. The incarceration of people with serious mental illness is like that, and even though unplanned, it has been accelerating for decades. There really are no advocates for incarcerating people with serious mental illness. Sheriffs and wardens universally complain that it should not be their job to take care of people with mental illness, and they certainly were not trained for the task.
There are a number of historic events that combined to send so many people with serious mental illness to jail and prison, including deinstitutionalizaton, "The War on Drugs," and changes in the criteria for a psychiatric defense. De-institutionalization involves the downsizing and closing of state and Veterans Affairs mental hospitals with the expectation that former patients (or, today, individuals who would have been candidates for state hospitals until the 1960s) would receive quality mental health care in the community. (4) But community mental health care, after an infusion of federal funds with President Kennedy's 1963 Community Mental Health Centers Act, would experience successive budget cuts and eventually, by the 1990s, prove vastly inadequate for the task of providing public mental health services. (5)
In the same period, there was the "War on Drugs" with attendant sentencing guidelines that sent an unprecedented number of low-level drug offenders to prison for longer terms. Of course, since "dual diagnosis," that is, psychiatric disorder plus substance abuse, is very prevalent, the War on Drugs landed a huge number of individuals with serious mental illness in our jails and prisons.
Meanwhile, the criteria for determining that a defendant is insane have changed. The "third prong" of many states' statutes on insanity, the criterion whereby a defendant, on account of a mental illness or defect, is unable to control himself and refrain from the criminal act, was taken off the books. (6) This change made it more difficult to prove a defendant is not guilty by reason of insanity (NGRI), resulting in more individuals with mental illness going to prison.
The growing proportion of prisoners with serious mental illness created a huge over-subscription for correctional mental health services and a glaring crisis in correctional mental health care today. For example, many prisoners with serious mental illness are warehoused in prison segregation units, where isolation and idleness exacerbate their mental illness. Others are consigned to general population units where mental health treatment is very thin, and they are too often victimized. Even when the prisoner in crisis is identified, and, for instance placed in an "observation cell" while he presents an imminent risk of suicide, on average there is too little actual treatment going on in the observation cells. Then, because correctional mental health services are relatively underfunded and oversubscribed, the prisoner in crisis is moved out too fast, often transferred back to a segregation cell from where he came, and receives inadequate follow-up treatment. This is why a disproportionate number of prison suicides occur in isolation cells, with prisoners who have cycled through the prison's observation unit. (7)
The high rate of suicide in prison is only one of many indicators that prison mental health services are far from adequate. There is a widely held but erroneous assumption that correctional mental health is relatively adequate, that the best place for the indigent individual with serious mental illness to receive treatment is behind bars. This assumption can actually serve to rationalize the consignment of even more individuals with serious mental illness to prison. Thus, in many states the law provides for a finding in criminal trials that the defendant is "guilty but insane." The jury can find the defendant guilty, not guilty, not guilty by reason of insanity (NGRI), or "guilty but insane." (8) Because many jurors actually believe that prison is the best place for a severely disturbed individual to receive needed mental health treatment, when given the choice, they opt for "guilty and insane." (9) Perhaps they also fear that a "NGRI" finding would result in the defendant eventually being released when the defendant seems too dangerous for that. But in the several states where I have investigated correctional mental health care and where "guilty but insane" is provided in the jury instructions at trial, prisoners who have been found "guilty but insane" do not receive any different mental health care than do other prisoners, and for the most part that care is quite substandard.
While the prison population has grown exponentially and the proportion of prisoners with serious mental illness also has expanded, mental health services in corrections have simply not grown apace. There are too many individuals with serious mental illness for the mental health staff to treat them adequately. (10) The oversubscribed mental health staff try to fulfill their professional duty. They may try focusing their energies on the "major mental illnesses," including schizophrenia, bipolar disorder, and major depressive disorder. Or in some states a decision is made to provide a larger "case load" psychotropic medications only. Or there is a tendency, neither articulated nor advocated by anyone in particular, to lock up the most seriously disturbed prisoners in some form of isolative confinement, usually punitive segregation but occasionally protective custody (which too often also happens to be an isolative confinement unit). In any case, prisoners with serious mental illness tend to go untreated, undertreated, or treated with medications and little else, and a disproportionate number wind up in isolative confinement. (11) Then the isolated prisoners with mental illness complete their prison term and need to return to the community. But the many years of inadequate treatment and harsh conditions, including prison crowding and long-term isolative confinement, have exacerbated their mental disorder and made them more disabled. (12) Then we read about prisoners with mental illness being released straight out of isolative confinement and perpetrating horrible crimes in the community. A very high profile and tragic example is the 2012 murder of Tom Clements, the Executive Director of the Colorado Department of Corrections, by a man who had recently been released from prison after spending years in solitary confinement. (13) The irony was that Director Clements had been advocating the downsizing of solitary confinement in the Colorado D.O.C.
Departments of correction cannot effectively address the mental health crisis behind bars in isolation from community groups and government agencies. The mental health crisis behind bars is not of correctional professionals' doing. It is a matter of poorly planned social policies--i.e., deinstitutionalization, incrementally diminished funding for public mental health services, a War on Drugs that captured many individuals with serious mental illness in its dragnet, changes in criteria for a psychiatric defense in court, and so forth--, so the social policies designed to address the mental health crisis behind bars must include consideration of such things as public mental health resources in the community, services available to ex-prisoners when they return to the community, low-income housing, jobs, and substance abuse treatment in the community.
In effect, our society needs to decide how we want to deal with serious mental illness and whether dreadful and harmful prison conditions and deprivations are acceptable in our democracy. It is no longer possible for politicians and the public to ignore the problem and leave individuals with serious mental illness to be arrested and sent to prison, where their fate is mostly invisible to the public. Mental illness can no longer be swept under the carpet. Media coverage of the ill effects of isolative confinement, as well as correctional officers' excessively violent measures with prisoners who suffer from mental illness, opens the discussion to a larger public. The relegation to jails and prisons of a large proportion of people suffering from mental illness was not a well-considered policy, but the remedy will require careful deliberations about our social priorities.
THE COMMUNITY MENTAL HEALTH MODEL