Managing Mentally Ill Inmates in Prisons

• Date: 01 August 2008
• Published date: 01 August 2008
• Author: Joseph Ferrandino,Kenneth Adams
• DOI: 10.1177/0093854808318624
• Subject Matter: Articles

MANAGING MENTALLY ILL INMATES
IN PRISONS
KENNETH ADAMS
JOSEPH FERRANDINO
University of Central Florida
Mentally ill inmates now comprise a substantial portion of the prison population and pose administrative and therapeutic
challenges to prison administrators and mental health professionals. Some evidence suggests that both the size of the popu-
lation and the seriousness of their illnesses are increasing. Given this context, several issues are highlighted and discussed in
terms of contemporary efforts to deal with mentally ill inmates. Specifically, discussion centers on the use of actuarial devices
for prediction and classification, the conflict between treatment and control and the relation between treatment and manage-
ment, the distinction between risks and stakes and use of the environment as therapy, use of medication and isolation, and the
role of correction officers in mental health treatment. The authors make an argument for more sophisticated approaches in
dealing with mentally ill inmates that rely on expanded therapeutic options, broader role definitions for prison staff, and an
evidence-based approach for individualizing treatment.
Keywords:
mentally ill inmates; treatment; management
By all objective measures, correctional facilities in the United States have become the
primary mental health institutions in the nation (American Psychiatric Association,
2004; Fellner, 2006; Treatment Advocacy Center, 2007). As a result of the deinstitutional-
ization movement, state hospital populations went from 550,000 psychiatric patients in 1956
to 61,700 in 1996, for a decline of nearly 90%. These patients were released to the commu-
nity, often without adequate support services, and many later found themselves caught up in
the criminal justice system. Thus, it is unsurprising that presently the three largest psychi-
atric institutions in the country are the Los Angeles County Jail (17,000), New York City
Rikers Island (13,500), and the Cook County Jail in Chicago (9,000) (Parker, 2006).
A number of research studies have certified that a substantial number of mentally ill per-
sons are housed throughout our state and federal prison systems. Although specific esti-
mates vary depending on the research methodology and definition of mental illness used
(Toch, 2007), the proportion of mentally ill prison inmates is generally estimated to be
around 16% (Ditton, 1999), based on mental health service records. The problem of men-
tally ill inmates in prison is serious and substantial, and indications are that the situation
may be getting worse. Data from the Florida Department of Corrections (n.d.) highlight the
potential urgency of the situation. The 2005-2006 annual report indicates that “16.5% of
Florida’s inmates receive ongoing mental care” (p. 47). Inmates who receive care are clas-
sified into three categories of mental disorders: mild (S1 and S2), moderate (S3), and severe
AUTHORS’ NOTE: Correspondence concerning this article should be addressed to Ken Adams, University of
Central Florida, College of Health and Public Affairs, 3280 Progress Dr., Orlando, FL 32826-0544; e-mail:
kenadams@mail.ucf.edu.
CRIMINAL JUSTICE AND BEHAVIOR, Vol. 35 No. 8, August 2008 913-927
DOI: 10.1177/0093854808318624
© 2008 International Association for Correctional and Forensic Psychology
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CRIMINAL JUSTICE AND BEHAVIOR
(S4 to S6). Looking at the historical picture, we find that from 2002 to 2006, the number
of “mild” inmates fluctuated but essentially remained unchanged over time. However,
inmates classified as “moderate” increased by nearly one third, going from 8,053 to 10,553,
whereas inmates classified as “severe” doubled, going from 402 to 812. Clearly, Florida is
admitting over time greater numbers of inmates with more serious mental illnesses. Given
that Florida has the third largest prison system in the country, it may not serve as a bell-
wether for trends in other states. However, experiences in the Oklahoma prison system,
where the number of inmates on psychotropic medication tripled from 1998 to 2005, would
seem to corroborate Florida’s experience (Fields, 2006).
In terms of specific illnesses, prison inmates tend to have the same disorders as the gen-
eral population, albeit with greater frequency and intensity. According to the American
Psychiatric Association (2004), the most common mental illnesses in the inmate population
are depression, schizophrenia, and bipolar disorder, a finding that applies to prisons in both
the United States and the United Kingdom (Gordon, 2002). Inmates are also more fre-
quently diagnosed with personality disorders, a situation that is confounded by antisocial
personality disorder, which has as its primary diagnostic criteria antisocial or criminal
behavior, so it is a diagnosis for which most inmates qualify. Finally, inmates are more
likely to have co-occurring substance abuse disorder. For example, one study found that
about 45% of mentally ill jail inmates showed comorbidity of a major mental illness and a
substance abuse disorder (Young, 2003). Co-occurring disorders are more difficult to treat
because the illnesses can interact with each other and because treatment strategies for the
individual disorders may be at odds with each other.
In many respects, we already know much about the contours of the inmate mental health
problem, and we also know that solutions are complex and gaining in urgency. More inmates
with mental illness and more inmates with serious mental illness are entering our prison sys-
tems, and there is little reason to believe that this trend will reverse. Given that a significant
expansion of resources for state psychiatric care systems is highly unlikely, prison adminis-
trators have come to recognize that they need to develop programs, techniques, and strate-
gies to effectively manage this population. A recent report acknowledged as much by noting
that “finding safe, humane, and non-punitive methods for handling inmates who are experi-
encing the symptoms of mental illness is an ongoing challenge for prison administrators”
(Oregon Department of Corrections, 2004, p. 45). Despite the high prevalence of mentally
ill inmates, the U.S. Bureau of Justice reported that in 2000 only 51% of state prisons pro-
vided 24-hour mental care (Beck & Maruschak, 2001). Thus, correctional management is
playing catch up with this problem. This article discusses some of the major issues that need
to be addressed as attempts are made to improve inmate mental health care.
INTAKE, SCREENING, AND ASSESSMENT
Prisons have opportunities at a variety of junctures to identify mentally ill inmates, and
perhaps the most widely used juncture is intake. According to a Bureau of Justice Statistics
report, about 70% of state prisons screened inmates for psychiatric illnesses at intake in
2000 (Beck & Maruschak, 2001). A variety of screening instruments and practices have
evolved over time, ranging from clinical interviews and evaluations to actuarial or statisti-
cal approaches that minimize human judgments. At this juncture, the purpose of assessment

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is to identify mental health problems or potential mental health problems and evaluate their
need for treatment. Another goal is to identify inmates who are likely to be a danger to
themselves or others. With regard to screening and assessment practices, there have been
several notable developments.
During the past few decades, there has been continuing debate over the relative utility and
accuracy of clinical versus actuarial prediction models, especially in the context of predict-
ing dangerousness or criminal recidivism. For the most part, the debate has been resolved in
favor of statistically based actuarial models for predicting who is likely to be violent or to
reoffend. Monahan (1996) argued that because actuarial models are more accurate at pre-
dicting future behavior, they should be seen as a replacement for clinical approaches, rather
than as a supplement. He also noted that courts have found the clinical approach too unreli-
able, and thus, the catalyst for removing clinical elements from predictions is the justice sys-
tem itself. In a recent development, Banks and colleagues (2004) utilized a multitest
approach to actuarial risk, rating offenders on several instruments. Their focus was on con-
sistently identifying offenders rated as “high” or “low” risk across multiple tests in a type of
convergent validity strategy. Arguably, this strategy draws from the strengths of various
instruments and comes closer to allowing individuals, rather than groups, to be assessed
more precisely in terms of their probability of risk. The unique contribution of this research
is not in determining which test is best or most accurate but in combining several tests in
ways that allow for narrower or tighter specification of group at risk. Perhaps we will see
more such efforts at combining risk assessment instruments.
Taxman, Cropsey, Young, and Wexler (2007) summarized current uses of risk assess-
ment models by correctional facilities to assess substance abuse treatment needs and recidi-
vism. They found that in making treatment placement decisions, a majority (58.2%) of
institutions used a standardized substance abuse screening tool, and a minority (34.2%)
used an actuarial risk tool for gauging risk. They argued that use of these tools needs to be
expanded if high-intensity treatment programs, which often involve high-risk individuals,
are to increase and if treatment effectiveness is to be...