A reflection on the madness in prisons.

• Author: Lee, Bandy X.

INTRODUCTION I. Oddities II. The Mentally Ill in Incarceration III. The Mental Effects of Double Incarceration or Isolation IV. Legal Interventions V. Beyond Legal Interventions Introduction

On August 13, 2014, in one in a series of articles about the state of conditions at Rikers Island, New York City's main jail complex, the New York Times revealed:

The portrait that emerged from the report on Rikers Island by the United States attorney's office in Manhattan last week was of a place with almost medieval levels of violence, meted out with startling ferocity by guards and their superiors. The two-and-a-half-year investigation, which focused on the abuse of teenage inmates by correction staff, was exhaustive in cataloging the brutality. But a critical question that went unaddressed is how conditions were allowed to get to this point. Rikers has been a place of violent excess for decades. And the growing ranks of inmates with mental illnesses, reaching nearly 40 percent of the jail population today, have added to the challenges for correction officials. (1) The U.S. Attorney's Office report (2) and the Times investigative series were only the most recent salvos in a series of breaking news stories that have placed the experience of being a mentally ill inmate into the public discourse. Others have included legal rulings, such as the approval by Judge Lawrence Karlton of California's Eastern District of a plan to reduce mentally ill inmates in isolation in California prisons. Burgeoning commentaries in popular culture and conversation comprise only the surface of a growing civic movement. (3) For many readers of those reports, the contents were shocking and new; however, there is a significant medical and legal literature that has long documented these facts. From the mental health practitioner's perspective, this Article will explain that literature; how imprisonment affects those with and without mental illness, especially through solitary confinement (a condition that befalls those who are mentally ill especially frequently); and what to do about it.

1. ODDITIES

   Prisons are odd places for the psychiatrist to be practicing mental healthcare, yet they are our de facto mental institution. The above reports reiterated what the senior author4 of this Article saw in her daily work as a staff psychiatrist at Rikers Island. There, she treated hundreds of inmates with mental illness next door to the facility's emergency medical clinic, which received a daily flow of inmates beaten to the point of losing consciousness. Treating the damage seemed paradoxical in a setting where injuries were so often the deliberate product of other inmates or, as documented in the Rikers report above, the guards themselves. Less visible but equally present were the psychological injuries. Thirty minutes of therapeutic intervention per month would be counteracted by 731.5 hours of punitive, degrading, and wounding treatment. Medication often did not get delivered by staff, who might find it inconvenient to wake a patient at four-thirty in the morning, even if the patient, desperate to receive it, had been awake much of the night trying not to miss it (inmates are usually not allowed to hold psychiatric medications themselves).

   And what happens to the severely ill? Since a loss of insight, and the accompanying refusal to admit that one is ill and needs help, are hallmarks of many mental illnesses, those who need care the most are the least likely to receive it. In fact, many severely ill individuals did not even get to the psychiatrist's office for an evaluation. Once, when asked to screen an inmate being taken into punitive segregation for not following orders, the senior author found him to be floridly psychotic--yet he was miscategorized as someone without any mental health problems because he was withdrawn, quiet, and in denial of his illness. Since their daily exposure is to correctional staff who are not trained in mental health, or rather are trained to view aberrant behavior as primarily a security concern, mentally ill individuals are very likely to be placed in solitary confinement or isolation for "better management" rather than to receive treatment. (5) The myth of Sisyphus describes it well: one's attempt to treat is like rolling a boulder up the hill, only to watch it roll back down.

   Some officers did not seem to believe that mental symptoms could be serious: one officer, attempting to be friendly to the senior author, suggested that an inmate be placed under suicide precaution as "punishment" for reporting suicidal ideation more than a few times--insinuating that a duration of being stripped in a cold, concrete room with a single mattress would "cure" him of the desire to fabricate symptoms. He did not seem to recognize the callous unconcern he was unwittingly communicating--not to mention the potential danger to a human life. The seemingly extraordinary stance of this officer was not exceptional at Rikers or at any of the more than dozen other maximum-security facilities where the senior author had worked in her survey of maximum-security prisons around the country; rather, it was routine. A peculiar worldview seems to take shape in parallel with the peculiar surroundings; shared among insiders, it gets sheltered in by a barrier as thick as its walls. Behavior that does not adhere to rules is first interpreted as defiance, with the erratic, unpredictable kind posing the greatest risk to safety--which can be true, when the staff does not understand it. Those who end up in solitary confinement for punishment or management reasons are more likely to attempt or to commit suicide (6) and to have psychiatric symptoms (7) but actually receive less treatment because of logistical barriers to getting them to the clinic (e.g., requiring more than one escort) or, if they are seen at the door side, because of confidentiality issues where hearing the other is difficult without shouting, where officers and other inmates can hear. Group therapy and other structured activities that have educational, recreational, or life-skills training benefits are inconceivable in a situation of 23- to 24-hour lock down (in the senior author's experience, the one-hour-per-day out of cell time is often taken up with showers or exercise in a solitary courtyard, if taken at all, as logistical difficulties or the inmates' "giving up trying to ask for it" may result in its cancelation).

   The denial of medical and mental healthcare would be dangerous and damaging for any population. Here, we are facing a jail population that is 64.2% mentally ill and state and federal prison populations that are 56.2% and 44.8%, respectively. (8) Since substance abuse masks many symptoms, is not counted as a mental illness, and is a method of "self-medication" for many who cannot afford care, these numbers are most likely underestimates. Furthermore, those with personality disorders are not included even though personality disorders can sometimes be as lethal or as debilitating as major mental illnesses. Nevertheless, these numbers show that the rate of mental illness amongst the incarcerated is at least five times the rate of mental illness in the general adult population (11%). (9) A person suffering from a mental illness in the United States is at least three times more likely to be incarcerated than hospitalized.10 Los Angeles County Jail and Rikers Island have become the largest de facto mental institutions in this country. Nevertheless, those with mental illness are usually subject to harsher treatment, longer sentences, and leave jails or prisons sicker than when they entered. In an extreme example, also at Rikers, a mentally ill, homeless veteran on medication, who was arrested a week earlier for sleeping in a stairwell of a public housing building, died when his cell heated to over 100 degrees. (11) In mental healthcare settings, heat is generally monitored due to its potentially lethal interaction with common antipsychotic medications.

2. THE MENTALLY ILL IN INCARCERATION

   The circumstances which led to this disproportionate representation of mental illness in the correctional setting did not arise by happenstance but rather is a tragic consequence of inadequate community mental healthcare and an indicator of where our society has chosen to make its investments. There are two principal reasons.

   First, the nation failed in its attempt to "deinstitutionalize" the mentally ill, as it planned to on a large scale since the late 1960s, with the development of psychiatric medications that would make this possible. The plan was well-meaning, with the intent to release the patients from mental hospitals and to treat them in the community, where they might lead more normal lives. Only the first half of the plan was ever carried out, however; the second half, which depended on the creation of community-based housing and treatment facilities, was largely ignored or defunded, resulting in an outpour of unstable and ill individuals literally onto the streets. In a recent three-year period alone, $4.35 billion in funding for mental-health services was cut from state budgets across the nation. (12)

   Second, the United States experienced an unprecedented year-by-year increase in rates of penal incarceration, beginning at around the same time, in the mid-1970s, to a rate that is sevenfold of the average of U.S. history up to that point, and higher than that of any other nation on record today. (13) Again, this was the result of a well-meaning effort to protect the public, beginning with President Nixon's call for "wars" on crime and on drugs. Even after the national crime rate dropped by more than 40% over the last twenty years, the incarceration rate has scarcely dwindled, and public investment in prisons outweighs that of higher education or the treatment of mental illness. According to the U.S. Bureau of Justice...