ECLECTIC RANT: For Better Treatment of the Mentally Ill in Prisons and Jails

By Ralph E. Stone
Friday April 25, 2014 - 11:30:00 AM

From 1770 to 1820 in the United States, the mentally ill were routinely confined to prisons and jails. In the 1840s, activist Dorothea Dix lobbied for better living conditions for the mentally ill after witnessing the dangerous and unhealthy conditions in which many patients lived. Over a 40-year period, Dix successfully persuaded the U.S. government to fund the building of 32 state psychiatric hospitals. By the mid-1950s, there was a push for deinstitutionalization and outpatient treatment began, facilitated by the development of a variety of antipsychotic drugs and a move toward community-oriented care. It was thought that psychiatric patients would have a higher quality of life if treated in their communities rather than in isolated mental hospitals.  

Since 1970, because of a reduced availability of state hospital beds, lack of affordable housing, and underfunded community treatment, the mentally ill have been more often confined to prisons and jails.  

At their maximum census in 1955, the state mental hospitals held 558,922 patients. Today, they hold approximately 35,000 patients, and states are continuing to close beds to reduce that number. In 2012, there were estimated to be 356,268 inmates with severe mental illness in prisons and jails. There were also approximately 35,000 patients with severe mental in state psychiatric hospitals. This means that there are ten times the number of persons with serious mental illness in prisons and jails than in state psychiatric hospitals.  

The problems associated with placing the mentally ill in prisons and jails include: the mentally ill are confined longer than other prisoners; behavioral issues; victimization of the mentally ill prisoners; deterioration of their conditions because of lack of treatment; a disproportionate number placed in solitary confinement which exacerbates their condition; a disproportionate number of suicides; higher rates of recidivism.; and increased taxpayer costs.  

It is probably unfair to blame the poor treatment of the mentally ill in prisons and jail entirely on the prison and jail personnel for they have few options as they are usually untrained or equipped to house hundreds of thousands of mentally ill prisoners. In many cases, they do not have the necessary psychiatric medications and instead rely in many cases, on solitary confinement or restraint. 

It has long been established that under the Eighth and Fourteenth Amendment to the Constitutional, persons have the right to medical and psychological care while in prison or jail. To deny needed medical and psychological care is to add punishment in excess of the punishment imposed by the sentencing court. For example, here in California, the U.S. Supreme Court in Brown v. Plata, ruled that California's overcrowded prison system could not provide anything close to adequate medical or health care to its 147,000 prisoners. Justice Anthony Kennedy wrote: “Prisoners retain the essence of human dignity inherent in all persons. Respect for that dignity animates the Eighth Amendment prohibition against cruel and unusual punishment.” The Supreme Court ruled that California must remedy the situation by reducing its prison population to 137.5 percent capacity from the current 175.5 percent. 

In "The Treatment of Persons With Mental Illness in Prisons and Jails: A State Survey" (Survey) outlines what is needed is to maintain a functioning public mental health treatment system so that mentally ill persons do not end up in prisons and jails. The Survey recommends: 

* Reform mental illness treatment laws and practices in the community to eliminate barriers to treatment for individuals too ill to recognize they need care, so they receive help before they are so disordered they commit acts that result in their arrest.  

* Reform jail and prison treatment laws so inmates with mental illness can receive appropriate and necessary treatment just as inmates with medical conditions receive appropriate and necessary medical treatment. 

* Implement and promote jail diversion programs such as mental health courts. 

* Use court-ordered outpatient treatment (assisted outpatient treatment/AOT) to provide the support at-risk individuals need to live safely and successfully in the community. 

* Encourage cost studies to compare the true cost of housing individuals with serious mental illness in prisons and jails to the cost of appropriately treating them in the community. 

* Establish careful intake screening to identify medication needs, suicide danger, and other risks associated with mental illness. 

* Institute mandatory release planning to provide community support and foster recovery. 

* Provide appropriate mental illness treatment for inmates with serious psychiatric illness.  

The authors of the Survey propose a "Model Law" for inmate treatment to authorize city and county jails to administer nonemergency involuntary medication for mentally ill inmates in need of treatment.