Stop warehousing the mentally ill in prisons

On May 26, Chicago’s Cook County Jail appointed a clinical psychologist as its executive director. Some 25 to 35 percent of the jail’s “9,000 inmates suffer from serious mental illness, making it the largest mental health institution in the country,” Cook County Sheriff Thomas J. Dart, said in a statement last month.

Over the last few years, the Cook County Jail has experienced a spike in the number of mentally ill inmates amid deep cuts to mental health services. Activists say the selection of a psychologist is part of a growing recognition for the criminal justice system’s unsuitability for those with mental illness. Given their difficulty adapting to the violent and rigid culture of incarceration, mentally impaired inmates are particularly vulnerable. And because correctional facilities are not designed for this population, they are inflicting grievous harm on those inmates.

Statistics on the use of force by corrections staff against people with mental disabilities are lacking. But in a new report earlier this month, Human Rights Watch (HRW) released the first comprehensive review of the mistreatment and abuse of mentally ill inmates in prisons and jails across the country. The report estimates that 1 in 5 U.S. prisoners exhibits signs of serious mental illness and many more experience less severe or intermittent symptoms. Yet in the vast majority of states, prisons and jails are the biggest mental health institutions.

There are 10 times as many people with serious mental illness in prisons and jails as in psychiatric facilities, according to the Treatment Advocacy Center, a Virginia-based nonprofit group that promotes access to mental health care. A recent study by the Urban Institute, a think tank based in Washington, D.C., found that more than half of state inmates and nearly half of federal inmates have mental health problems yet only one-third of state prisoners and one-sixth of jail inmates report that they have received treatment. When treatment provided, it is often limited to medication and is not tailored to the individual mental health needs of inmates.

The prospects for mentally ill inmates were not always so bleak. The deinstitutionalization movement of the 1970s, which advocated for community-based treatment of people with mental illness, was hailed as a watershed moment for their humane care. Instead of warehousing the mentally ill in abysmal and countertherapeutic institutions whose bleak vistas now serve as the backdrop for horror movies, the government pledged to develop robust community treatment programs to enable those with mental disabilities to live in minimally restrictive environments.

But the initial promise of more humane treatment never materialized when funding and political will gave way to other priorities and social safety nets were gutted.  Now the demand for community and residential mental health programs far outstrips the supply, and those seeking or requiring treatment often languish without support on the margins of society.

To make matters worse, there are few alternatives to incarceration for minor offenders whose mental illness minimizes their culpability and for whom prison will likely worsen their conditions. As a result, the U.S. effectively reinstitutionalizes the mentally disabled population it once vowed to treat humanely. Unfortunately, many mentally ill inmates now leave correctional facilities more impaired then when they entered.

Incarceration is inherently stressful for inmates and corrections staffers alike. But the demands of compliance with rigid schedules, unyielding rules and hierarchies among both staff and inmate populations can be uniquely challenging for those already struggling to manage the symptoms of mental illness, which can range from depression and anxiety to severe psychosis. Yet understanding of and treatment for mental illness is woefully inadequate among corrections authorities.

The lack of treatment is compounded by the lack of training for corrections authorities and staffers to identify and manage behaviors related to mental illness. Poorly trained corrections workers often fail distinguish between belligerent and maladaptive behavior and erroneously presume prisoners are acting rationally and manipulatively instead of exhibiting signs of illness. Misapprehension about an inmate’s ability to control behavior can cause corrections staffers to engage in retaliatory treatment or impose punitive and counterproductive sanctions instead of more suitable interventions.

As the HRW report says, mistreatment can rise to the level of abuse, including the use of excessive physical force for cell extraction and other discipline, the use of harmful chemical agent and stun devices and excessive use of full body restraints. This often results in significant physical and psychological injuries and can traumatize vulnerable inmates, exacerbate symptoms and impede treatment and recovery. Without rehabilitation and treatment, inmates are released with little chance of successful reintegration into society. And community treatment, when provided, often consists of overwhelmed clinicians and poorly funded programs.

True, corrections authorities face a challenging and perilous job and are permitted to use force against inmates to ensure the safety and security of employees and other inmates. But the use of force is circumscribed by federal and international law, which prohibits torture and other cruel, inhumane or degrading treatment and requires accommodations for people with disabilities. Corrections staffers are allowed to employ force only to the extent required to control a situation, and its punitive use is impermissible. Yet HRW documented widespread use of force against inmates whose behavior was symptomatic of mental illness, often for misconduct that was minor and nonthreatening, such as profane language or banging on a cell door.

Aside from the individual harm, warehousing mentally ill in the criminal justice system is more costly, socially and financially, than providing appropriate mental health treatment. Instead of investing more money on mental health programming, governments at all levels are cutting budgets. According to the grass-roots advocacy organization National Alliance on Mental Illness, from 2009 to 2012, states cut mental health funding by $1.6 billion — a nearly 10 percent decrease.

The current approaches to managing mentally ill criminal offenders are counterproductive and misguided. Appointing a psychologist to direct a jail is a laudable first step in repairing the flawed system. But that is not enough. Comprehensive reform must include adequate funding for robust treatment and rehabilitation programs and training and oversight of corrections staffers, including accountability for abusive conduct. Most important, states must invest in appropriate community mental health treatment and diversion programs to keep those with mental illness out of jails and prisons in the first place.