Professor Glenda Snell
Eradicate the Incarceration of Persons with Mental Disabilities
“Prisons were never intended as facilities for the mentally ill, yet that is one of their primary roles today.” – Sasha Abramsky
In 2013, I was reported missing. In the midst of a mental breakdown, I had fled town, driving northward until my truck broke down in San Leandro, in Northern California. I had thrown away my cellular phone. I had no way to get ahold of anyone and very little money. At that point in time, I had no idea that I suffered from a mental disorder. All I knew was that I had started hearing voices, became very paranoid, and thought I was some sort of a government conspiracy whistleblower. It was terrifying and confusing, and after a week of roaming the streets, I had deteriorated to the point where everyone I encountered thought I was homeless. I attempted to rent an RV with a fake name, and when the rental place refused, I drove off their lot inside a stolen one anyway. I was trying to get to Half Moon Bay, where a friend’s mother lived, thinking I might be able to track her down somehow without a phone. Of course, I soon had a “parade” of police cars following me, with their sirens blaring and lights flashing. I was arrested and charged with three felonies, though one was immediately dropped (evading a peace officer), I still had two to deal with, but first, I went to jail.
The first night in the San Mateo County jail, they tried to put me in with the general population. I completely freaked out, and eventually they began to realize that I wasn’t on drugs (I was repeatedly asked if I was on meth) but that there was something seriously wrong. I was transferred back to medical, my clothes and bed were taken away. I was put into this large, Velcro outfit that I couldn’t harm myself with, and I was put on suicide watch. (I realize now that I was so lucky that someone recognized my symptoms and they were able to get a psychiatrist in to interview me in the middle of the night.) I was immediately put on lithium and given a diagnosis of Bipolar Disorder Type 1. After a few days in a solitary room on medication, I was transferred into a shared rooming facility in the medical wing. When it seemed likely that I wasn’t going to harm myself or anyone else, I was moved back into general population. I spent two weeks in jail before my mental faculties stabilized to the point where I realized I could bail myself out. The whole experience was supremely confusing, embarrassing, cost me my job and many friends. And I was one of the lucky ones. My family managed to get me a $7,000 lawyer. I received a plea deal based on a psychiatrist interview shortly after I was released, and plead no contest to a misdemeanor of joyriding. I truly believe that had I simply signed the papers in jail for the public defender that I would have been sentenced and would have spent far longer than two weeks in San Mateo County.
My experience is far from unique. Jamie Fellner, of the Human Rights Watch, wrote that the Treatment Advocacy Center recently estimated there were 356,000 persons with mental illness behind bars. Incarceration makes mental illness worse, and prisons are unprepared to deal with the mentally ill and mental healthcare crisis. While in jail, every day, I would stand in line for pill call with easily 1/3 of the population. Solutions are needed in order to properly process and care for the mentally ill within the prison system.
There has been a lack of adequate research in determining which jails and prisons need the most help and how best to go about it. Author Seth J. Prins wanted to provide a broad view of mental illness in prisons after realizing most works cited only two federal reports from 1999 and 2006, so “the author undertook a systematic review of 28 articles published between 1989-2013.” The study concluded that not only are these issues widespread, it is difficult to tell how widespread, as there has been a lot of fluctuation in the numbers of mentally ill reported in prisons. There are wide variations when self-reporting, however, many seriously mentally ill inmates are not competent to consent to self-report. A full mental health screening for every inmate currently incarcerated is called for. We must begin with accurate information in order to see precisely the magnitude of the crisis that we are experiencing in the judicial system.
Perhaps complicating the issue is the fact that for-profit prisons make money off of bodies in cells. If mentally ill inmates are diverted into other programs or facilities, there will be a substantial decline in the number of inmates held in these for-profit prisons. A complete overhaul of the prison system is necessary, and we must start by caring for persons with mental disabilities, not locking them up. We must implement policies and programs and procedures for dealing with the mentally ill in a compassionate way.
Another factor may have to do with poverty. “Poverty is a common element among many mentally ill inmates, even homelessness.” (Prins) It was certainly true for myself and the people I encountered during my escapade. The way the current system is set up, homeless people can receive encroachment tickets for having their things out in public with them. Once they’ve received enough tickets that they cannot pay, they wind up in jail without the money to bail themselves out. Bail reform is something that Senator Kamala Harris has recently taken up in California. Far too many people linger in jail for longer than necessary due to these bail restrictions.
Another law, I feel is cruel, is the three strikes law. As Tala Al-Rousan wrote in “Inside the Nation’s Largest Mental Health Institution: A Prevalence Study in a State Prison System,” evidence suggests mentally ill persons are more likely to break rules, get in fights, be reprimanded by adding more charges to their time and spend more time in jail than someone who is not mentally ill. Once they’ve reached three strikes, they are now handed lifelong prison sentences.
Not only are mentally ill inmates more likely to be exploited by other inmates, they are more likely to break rules themselves. Abramsky noted in her article that the mentally ill face higher than average disciplinary rates, and lack of behavioral control, “Many refuse to comply with orders like sit down, come out of a cell, stand for count, remove clothes from cell bars, take showers.” A lack of showering is an often-cited symptom of depression.
Do the wealthy pay for mental healthcare to help avoid incarceration for their children? Why wouldn’t they? It is much easier to stay healthy when one has health insurance and have the money to afford premiums, co-pays, medications and expensive healthier foods. Does this system contribute to the criminalization of the poor? If the poor are disproportionally represented in prison and also lack mental healthcare prior to incarceration, then it certainly does. “Poor people with mental illness receive only short-term treatment, are stabilized, sent back out into the community with limited access to treatment.” (Abramsky)
The poor are criminalized for being sick, and that is absolutely disgusting.
The mentally ill face a host of challenges. In Prins’ review, he found these common elements: poverty, unemployment, crime, victimization, family breakdown, homelessness, substance abuse, general health problems and stigma. One of the difficulties of stigma is that the actions of the mentally ill are treated as disciplinary problems rather than as symptoms of their illnesses being observed. The inadequate access to community treatment options prior to incarceration is a terrible burden, and as we have seen, many, many people are diagnosed in jail or prison. In the Iowa study, Al-Rousan found 48% of inmates had mental illness, of whom 29% had serious mental illness, and 99% of the inmates were diagnosed while incarcerated, as I was.
Mental illness often interferes with the ability of the prisoner to cope with life in prison. There is a “prison code” that exists, and mentally ill persons are more likely to break this code, snitch on another inmate, and receive retaliation for it. (Abramsky) This leaves people with mental illness vulnerable, and often frightened. Eyal Press’ article “Madness”, presented by The New Yorker, closely followed life in the Dade Correctional Facility. It was found that people with mental disabilities also face general ostracization and are called nicknames like “dings” and “bugs.” Anyone attempting to help an inmate, such as a psychologist, was known as a “hug-a-thug.” This created a hostile working environment for psychologists and case workers at this particular facility, which allowed for the lethal abuse of an inmate with a mental illness.
The abuse and neglect of the mentally ill in prisons is a horrifying subject. I actually found so many examples of neglect and abuse among various sources that I focused on a few cases, two of neglect presented by Fellner, and one of abuse all resulting in death, presented by Press.
Neglect: Anthony McManus, a prisoner in Michigan, died in 2005. He was age 38, weighing a mere 75lbs. Although bipolar and schizophrenic, he was confined in a prison with no psychiatry department. He was pepper sprayed three days before his death and videotaped asking for food and water, although none was provided and his official cause of death was myocarditis and emaciation. (Fellner)
Neglect: Christopher Lopez, an inmate in Colorado, was 35 years old when he died at San Carlos Correctional Facility in 2013. He was schizophrenic and died from severe hyponatremia, which is too much psychotropic medication leading to low sodium in the blood. It is easily identifiable via blood test and treatable, but the nurse(s!) never took his vitals. He was kept in a room 22-24hours a day. (Fellner) Solitary confinement is cruel and unusual punishment, and it should never be used to discipline persons with mental disabilities.
Abuse: Inmate Darren Rainey was boiled to death in a hot shower in June 2012 in Florida at Dade Correctional Facility, where the incident was then covered up. Guards were seen laughing about “putting him in the shower” to discipline him, but the shower was hot enough to make coffee. (Press)
These cases were extreme, but not unique. Correctional Officers, or COs, use excessive force in many cases, and further compassionate training is required. Even when there the proper equipment is provided, such as restraining chairs or psychiatric beds, they are often misused.
There are many challenges to getting prisoners the mental health care they need. Abramsky noted that understaffing, poor screening and tracking of mentally ill prisoners, lack of timely access to mental health staff (guards are not referring prisoners often enough, and “bizarre behavior” is not enough for a referral, though it certainly should be when viewed as a symptom!), diagnosis of malingering (faking it, or manipulation), using medication as the sole treatment strategy, and a lack of confidentiality between the prisoner and the mental health staff all add barriers to prisoners receiving the help and medical attention they need.
I find some comfort knowing that some places are truly making an effort to integrate solutions to the mental health crisis. Tom Dart is an Illinois sheriff. Angela Bradbery wrote about his program for Public Citizen News. “Dart, who oversees one of the largest jails in the country, has implemented changes that have made his jail a role model for humanely managing seriously mentally ill inmates.” (Bradbery, 1) Dart manages his inmates in a number of ways that compassionately support the mentally ill. All staff receives mental illness training. Their jail provides full treatment, and upon release, transitions them to community resources. Once free, access to a 24-hour care line is available for mentally ill ex-inmates. This example is one to be mimicked around the country. Tom Dart has managed to show that some people do care, and that it can be done with proper planning and implementation.
Politicians and the community have failed the mentally ill. Mentally ill persons wind up in prison when they are left untreated within the community until their symptoms have gotten so bad that they commit a crime. The word “transinstitutionalization” refers to the problem of persons with mental illness being left untreated until they end up institutionalized within correctional settings. (Abramsky) This is certainly what happened to me. My symptoms had been getting worse for months prior to my leaving town, and I worsened to the point of not having the self-awareness necessary to monitor my moods. “Thousands of mentally ill are left untreated and unhelped until they have deteriorated so greatly that they wind up arrested and prosecuted for crimes they may never have committed had they been able to access therapy, medication, and assisted living facilities in the community.” (Abramsky) Reform is needed and public funding and support is needed. Stigma must be decreased and people must speak openly about mental healthcare in order to influence public opinion and garner support. These changes can happen, and should.
Solutions are desperately needed to help with the mental healthcare crisis facing both prisons and communities today, for these problems are intertwined. Early preventative care and mental health screening in the community would greatly curb the number of people with mental disabilities being introduced to the criminal justice system to begin with, as they would have access to medications and therapy.
Therefore, I propose a whole host of solutions to offer compassionate methods of processing persons with mental disabilities. To begin, it would be helpful if police received extensive training in recognizing mental health crises. When I was on the streets, I had several interactions with police officers prior to my incident and arrest. None of them realized I was a missing person, and while they obviously could tell something was wrong, they had nowhere to take me and ultimately just released me back on the streets. Ideally, my symptoms should have been identified, and then the police could have transported me to facilities that do not yet exist. Some cities have PERT (Psychiatric Emergency Response Team) which sends out a psychiatrist along with a police officer. Together they determine where the individual needs to be taken. These PERT teams should be in all cities and be standard procedure.
The United States is in desperate need of more specialized facilities for the mentally ill. These facilities would need to process individuals in mental health crisis that have committed no crimes and are therefore free to go as long as they are not posing a threat to themselves or others and not be turned away for lack of insurance.
For the prisoners, there need to be acute crisis care units and intermediate care units with psychiatric beds for long-term care and rehabilitation in all facilities. Each location should include 24-hour psychiatric care and monitoring.
Bail reform is something that would reduce the criminalization of the poor. This can ruin lives, as the incarcerated can lose their jobs, their income and have no one to care for their children. Innocent until proven guilty should not include a bail system that is not intended to be, but is nonetheless, punitive.
Doing away with encroachment tickets would be a great start to reducing the criminalization of the homeless.
Another helpful solution would be the development of a kind of homeless daycare center. Think of it like a park, maybe with a library, with lots of shade and water fountains and bathrooms and showers and large lockers for their things. There could even be an on-site psychiatrist and psychologist available, and administrative staff to assist people with applying for health insurance, disability, and other forms of government assistance. In my utopia, this place already exists, funded completely by taxpayers.
The development of mental health applications has been a new and novel thing. Some apps help time breath, mood swings, all sorts of things. I don’t see why we haven’t seen applications that allow people to report mental illness they see in others (perhaps a PERT team can respond?) or, perhaps even more important, an app that puts the mentally ill in direct contact with help when they are in mental crisis. I’m not talking about a suicide hotline, I mean an app where I can press some buttons to say, “I’m hearing voices and losing my mind, what do I do?” and get put in immediate touch with a psychiatrist, assistance, a PERT team, anything. This is the next logical and necessary step.
Once a crime has been committed, there are many solutions that will aid in the compassionate processing and interfacing with mentally ill inmates. Firstly, as Abramsky points out, low level drug offenders are often diverted into substance abuse treatment programs. Since large numbers of the mentally ill also have substance abuse issues, making this universal would reduce the numbers of mentally ill in prisons. There should also be a diversion program in place for those who do not have substance abuse issues, but do have a history of mental illness. They should be diverted to intermediate care units for rehabilitation with minimum security.
Moving beyond training COs, there need to be treatment programs in place for inmates. There should be group therapy, solo therapy, medications should be introduced and tapered carefully, with staff in place around the clock. Pre-release care is important, as is a smooth transition to community resources for the recently released. I approve of Tom Dart’s 24-hour care line for mentally ill former inmates and think more places, if not all facilities, should implement such a solution.
We have abandoned the mentally ill to the streets and prison system, to struggle with substance abuse issues and endure a number of hardships. Deinstitutionalization has created a public health crisis in the United States. Careful consideration and decisive action is needed to universalize and standardize the mental healthcare system. The mentally ill do not belong in prisons simply for being mentally ill and need to have access to round-the-clock care in facilities that are designed with their needs in mind. I am so grateful for the care I received while I was incarcerated. This is not some luxury, it is a constitutional right to medical care, and it is needed now.
Abramsky, Sasha, and Jamie Fellner. “Ill-Equipped U.S. Prisons and Offenders with Mental Illness.” Human Rights Watch, Open Society Institute, 21 Oct. 2003, www.hrw.org/report/2003/10/21/ill-equipped/us-prisons-and-offenders-mental-illness#912713.
Al-Rousan, Tala, et al. “Inside the Nation’s Largest Mental Health Institution: a Prevalence Study in a State Prison System.” BioMed Central, BMC Public Health, 20 Apr. 2017, bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4257-0.
Bradbery, Angela, and Delaney Goodwin. “National Survey Shows County Jails Unequipped, Overwhelmed With Seriously Mentally Ill Inmates.” Public Citizen News [Washington, DC] 1 Oct. 2016, Vol. 36, No. 5: 1+. Print.
Fellner, Jamie. “Callous and Cruel Use of Force against Inmates with Mental Disabilities in US Jails and Prisons.” Human Rights Watch, Human Rights Watch, 12 May 2015, www.hrw.org/report/2015/05/12/callous-and-cruel/use-force-against-inmates-mental-disabilities-us-jails-and.
Fries, Brant E., et al. “Symptoms and Treatment of Mental Illness among Prisoners: A Study of Michigan State Prisons.” International Journal of Law and Psychiatry, vol. 36, no. 3-4, Jan. 2013, pp. 316–325. Science Direct, doi:https://doi.org.ezproxy.palomar.edu/10.1016/j.ijlp.2013.04.008.
Press, Eyal. “Madness.” The New Yorker, The New Yorker, 2 May 2016, www.newyorker.com/magazine/2016/05/02/the-torturing-of-mentally-ill-prisoners.
Prins, Seth J. “Prevalence of Mental Illnesses in U.S. State Prisons: A Systematic Review .” Psychiatry Online, National Institute of Mental Health, 1 July 2014, ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201300166.