A person viewed from behind, wearing handcuffs.

A Nightmare of Prison Mental Health

The United States has been convulsed in recent years with arguments over mental health services, usually in the wake of rampage violence, which is blamed on mentally ill people regardless as to the mental health status of the culprit — to commit such crimes, evidently, is to be a ‘madman,’ regardless as to any actual evidence for or against that thesis. The sane want to see the insane locked away where we can’t hurt anyone, while the insane just want to access some mental health services so we can live our lives in relative health, happiness, and safety.

In other words, all we truly want are some basic human and civil rights, along with a recognition of the fact that we are human beings and deserve the same respect accorded to all people. Living with a mental illness does not make someone a criminal, and the increasing trend towards criminalising mental illness is both frightening and dangerous. It is turning mental health providers into police, police into mental health providers, and patients into pawns to be moved around a very dangerous and sometimes explosive chess board.

Within the United States, mental health services are simply out of reach for many people. Those struggling to access mental health care, especially during a psychiatric crisis or while dealing with treatment-resistant mental illness, have a shrinking number of options for finding and securing treatment.

In a 2008 report (.pdf), the Treatment Advocacy Center noted that for the 340 public hospital beds available per 100,000 people in 1955, by 2005, that number had dwindled to 17. They recommend that states maintain a minimum of 50 beds per 100,000 people — only one state, Mississippi, met that goal, and it was by the skin of its teeth, with 49.7 beds per 100,000 residents.

Medicare and Medicaid were supposed to provide support and treatment for people in the community, these systems failed many mentally ill people, and continue to do so.

This is a direct result of the deinstitutionalisation movement, which was driven by a number of agendas. Some mental health activists wanted to liberate forcibly institutionalised people from squalid, overcrowded, horrific, abusive conditions, for institutions in the 1950s (and today) were not necessarily places of healing that focused on patient welfare and recovery.

It was also driven by political agendas, with officials like Reagan wanting to cut spending in as many ways as possible. His decision to slash funding to public hospitals led to a mass exodus of mentally ill people into a world that provided absolutely no support network or followup — while Medicare and Medicaid were supposed to provide support and treatment for people in the community, these systems failed many mentally ill people, and continue to do so.

And it was driven by a shift in political attitudes about institutionalisation and how mental health should be handled. Rather than locking us away, mental health advocates and those working in solidarity with us argue(d), we should receive treatment and care in the community — but we still need access to beds when we require inpatient treatment for psychiatric crisis or major adverse events in our lives. And, critically, we still need access to a range of services so we can find a treatment modality and approach that works for us. When these aren’t provided, the results can be devastating.

Mental health services in the community are typically costly and can be difficult to access. Cuts to public health services across the US have reduced free and low-cost options for many people, forcing us to fight tooth and claw for even basic care. A push in medicine to focus on finding drugs that fit the patient and leaving it at that is leaving gaping holes in mental health coverage, as many patients don’t benefit from drugs alone, also requiring followup care and monitoring as they work on specific issues.

The only people who can access high-quality, consistent, stable mental health services are wealthy individuals with excellent insurance plans or enough private wealth to fund repeat visits to counselors, psychiatrists, and other mental health professionals. These individuals also have access to the few, and expensive, beds at private mental health care facilities for those who need or desire inpatient care — when hospitalizations can cost tens of thousands of dollars and may need to last a month or more, such services are logistically beyond the reach of many people.

…the prison system is becoming the primary care provider for millions of mentally ill people across the US.

In the face of the declining number of mental health services, one of the first lines of defense in mental health care has become police officers, who are tasked with responding to the scene when patients experience psychotic breaks and other traumatic events. Police officers are not trained to provide mental health services, as it’s not their job, and these encounters often go tragically wrong.

This situation speaks to a larger social issue, however, which is that the prison system is becoming the primary care provider for millions of mentally ill people across the US. One of the more immediate results of deinstitutionalisation across the US was a sudden rise in mentally ill inmates (as well as a spike in the homeless population), as mentally ill people found themselves falling into the prison-industrial complex when they couldn’t interact with a harsh and sometimes abusive outside world.

As mentally ill people are allowed to experience severe declines, they’re caught up by the justice system, and they wind up being sent to prison. This happens at all levels of the health care system. Patients who never interacted with care providers end up being sent to prison for being mentally ill, alongside those who did, but weren’t provided with adequate followup — for example, teens who attempt suicide and are booted out of their beds too soon can end up on the wrong side of the law as they continue to act out and struggle with complex emotions that they may not be able to process.

In some cases, people are actively advised to call law enforcement for mental health services, and health providers who are unable to provide the care their patients need may secretly hope for incarceration, as chilling as that sounds.

Matt Soulier, a juvenile forensic psychiatrist at UC Davis’ MIND Institute, said he sometimes finds himself wishing his patients would break the law. Once they’re in the juvenile justice system, he said, they have much better access to mental health treatments.

“It’s almost a blessing when they commit a crime,” he said. “We tell parents of patients every day, ‘As soon as your kid commits a crime, for sure call the police.’ ”

It’s a particularly acute problem for mentally ill children and juveniles, who have even fewer beds available than adults. For those with complex mental health conditions, bed availability is even more restricted; this is how children end up on adult psychiatric wards, or surrendered to the care of the state by parents who have been provided with no other options or support when it comes to providing what their children need and deserve.

This positions prisons and jails as mental health providers, just as they have also become health care providers for many inmates. Chronic illnesses like diabetes, HIV/AIDS, and hepatitis C are common within the prison system, often walking hand-in-hand with mental illness. Approximately 56% of state prison inmates have some form of mental illness, compared with roughly 45% of federal prison inmates and slightly over 64% of jail inmates. All of these inmates force a significantly higher risk of sexual assault and rape.

The National Institutes of Mental Health note that ~34% of state prison inmates, 24% of federal inmates, and 17.5% of jail inmates receive mental health services while they are incarcerated. As you can see, there is a severe mismatch between these numbers and those cited above: getting into prison is no guarantee of receiving mental health. And for those who do manage to get mental health services, those offered in prison are hardly comparable to what’s on offer at costly private clinics available to the most wealthy and powerful in society.

Jails and prisons do not, as one might imagine, make the best health care providers. Their primary function is as a warehouse for human beings, not as a facility where people can focus on medical issues and get well. Prison mental health in the United States is, bluntly, nothing short of atrocious, and it has been criticised extensively across the US — so much so that in some regions, like California, the system was actually taken into receivership over its failures to inmates.

In California, the decision to put prison health into receivership was based not just on mental health services but on overall quality of care, but mental health services certainly played a large role. This is a state, after all, where group therapy was performed with patients locked into individual cages. The state’s prison mental health services continue to be under investigation, and it isn’t the only one raising eyebrows in the United States in terms of the quality and quantity of care provided to prisoners.

Prisoners and advocates report a variety of abuses of mentally ill prisoners in the name of ‘mental health care,’ including over medication, beatings by guards, and more. In addition, prisoners are kept in highly stressful conditions which can exacerbate existing mental health conditions or contribute to the onset of health problems. Solitary confinement, for example, a practice widely accepted and used across US prisons, is considered torture by some authorities and most certainly isn’t good for mental health.

Imbalances in prison mental health services reflect external social imbalances in terms of who accesses care, when, and how. As on the outside, white prisoners tend to receive generally better mental health services, especially at minimum security or ‘white collar’ prisons, where white inmates can experience a far better overall standard of living than the majority Black and Latino populations of maximum security facilities.

Notably, the ACLU observes (.pdf), mentally ill prisoners tend to stay in prison longer than their cohorts, even though studies indicate that providing mental health services in the community or through public hospitals is far less expensive than offering them in custodial settings. The ACLU also finds that prison mental health failings disproportionately impact women:

Despite the soaring rates of women’s incarceration and women inmate’s mental health needs, most prisons lack adequate facilities, services, and programming for women prisoners. Therapeutic counseling is rarely available. As a consequence, women attempting to access mental health services are often denied care, or administered psychotropic medication without being offered psychotherapeutic treatment.

As well as juveniles:

About two thirds of child prisoners have at least one mental illness.  In its investigations of juvenile correctional institutions, the ACLU has found that this mental illness often stems from severe — often horrific — childhood sexual or physical abuse. Despite high rates of mental illness, including post-traumatic stress disorder, major depression, borderline personality disorder, and bipolar disorder, children in custody are subjected to a range of abuses.

The fact that the first option for mental health services in the US is the prison system should be disturbing. Some of the most vulnerable people in society are being put at a profound disadvantage by the failings of the mental health system and the use of police forces and the prison system as a psychiatric service provider. Rather than getting needed care in-community, where they belong, people are being subjected to abuses far from home in settings that are not therapeutic.

Mentally ill prisoners are more likely to experience additional health problems, including relapses of their mental health conditions caused by inadequate care, stress, or prison practices like solitary confinement. As a result, they may act out, attempt to organise their fellow prisoners (something prison officials fervently attempt to put down at all costs, as seen with abuse of hunger striking prisoners in California), or become involved in riots and other disciplinary events. The response is to slap them them with harsh penalties, which in turn exacerbate their mental illnesses even further, creating a vicious cycle that never fully lets up.

When a prisoner’s sentence finally ends and a release date arrives, the prisoner is dumped back out into the world with no offer of support, no followup, no social worker to help with accessing services, and no safety net. Unsurprisingly, many mentally ill ex-inmates find themselves tangling with law enforcement officers yet again, sometimes within weeks or months of incarceration, and they loop right back into the prison system again.

The United States cannot seem to comprehend a system in which mentally ill people access compassionate, comprehensive care that keeps them out of jail and prisons and in their communities, with beds available if they need them.

Mental illness becomes a tangled factor that makes it even more difficult to escape what is effectively a merry-go-round of incarceration and re-incarceration. Prisoners cannot step off without social support, which they do not receive causes comprehensive mental health services are not available in the United States, and consequently, they get sucked back on every time they consider trying to escape. Society watches, more or less indifferent, as vulnerable people are sucked into the black hole of the prison system, never to return.

Those most at risk of being caught in this dangerous snag are among the most marginalised of society. Low-income people, people of colour, and nonwhite people are disproportionately represented in the prison system in general, and this becomes especially acute when one looks at mentally ill prisoners. Those with money and Whiteness on their side can often escape the law enforcement to prison to disappearance pipeline, while those who don’t have access to these privileges may drown in the swamp of the prison system instead.

The issue of mental health in prisons is acutely intersectional, illustrating how a social issue can compound across multiple axes of oppression. To be mentally ill, in general, is to be at higher risk of going to prison; to be low-income, a person of colour, or a non-white person also increases your incarceration risk, quite significantly. To experience two or more of these things is to face a substantial risk that you will spend at least some time in prison during your lifetime, and that your very existence and identity will be criminalised in the name of ‘public safety.’

The United States sends mentally ill juveniles of colour to prison because it doesn’t know what else to do with them. It tells parents to call law enforcement when their children experience psychosis because mental health services to avert psychotic breaks aren’t provided (even though comprehensive services would be less costly than constant emergency interventions). It tells communities of colour to be patient with a broken justice system even though they can clearly see the disparities, just as everyone else can.

The United States cannot seem to comprehend a system in which mentally ill people access compassionate, comprehensive care that keeps them out of jail and prisons and in their communities, with beds available if they need them. Until it can, it is doomed to repeat the cycle of violence against mentally ill people through the prison-industrial complex.

Image: Victor/Flickr.