The Treatment of Persons With Mental Illness in Prisons and Jails: An Untimely Report

The recent 2014 Joint Report of the Treatment Advocacy Center and the National Sheriffs’ Association¹ could have been a most useful and timely report on the critical issue in correctional mental health today: the woefully inadequate access to appropriate levels of mental health services for the enormous and growing number of seriously mentally ill persons in jails and prisons. Instead, it is a tendentious monograph that will add to the worsening root of the problem, precipitously eliminating hospital treatment for severely mentally ill inmates.

[[{"type":"media","view_mode":"media_crop","fid":"26961","attributes":{"alt":"national survey of treatment practices for mentally ill inmates","class":"media-image media-image-right","height":"142","id":"media_crop_4836067846517","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2576","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image","width":"174"}}]]The purpose of the study was to conduct the first national survey of treatment practices for mentally ill persons in prisons and jails, with a focus on treatment-refusing, seriously mentally ill inmates. Among the sheriffs and administrators interviewed, there was consensus on 3 points:

• The number of mentally ill in jails and prisons continues to climb, and the severity of their mental disorders is worsening

• Jail and prison officers “feel compelled to provide the hospital-level care that these inmates need”^1(p6)

• “The root cause of the problem is the continuing closure of state psychiatric hospitals and the failure of mental health officials to provide appropriate aftercare for the released”^1(p6)

The implication is that the reduction of hospital and other mental health services for civilians has led to an increasing number of seriously mentally ill persons who end up behind bars. This public policy, which led to trans-institutionalization, is a big part of the root of the problem-the tap-root, as it were.

Unfortunately, there was no consensus about the increasing withdrawal of hospital services from seriously mentally ill inmates. The withdrawal of hospital mental health services from mentally ill inmates should have been concerning. Sheriffs and jail administrators may be able to do little about the reduction of services that leads to more mentally disordered persons being incarcerated. However, they can be concerned about and attempt to address the other side of this issue: the withdrawal of hospital services for individuals for whose care they are responsible. Because of the way it was designed and carried out as well as the way the data were organized and presented, rather than addressing the root cause, the survey promoted the practice/policy of introducing and supporting enforced medication in correctional settings and ignored the possibility of making hospital care available to inmates in need of this level of care.

This bias toward providing involuntary medication in jails and prisons rather than addressing the root cause is evident not only in the opening paragraph of the Joint Report, but also in the survey itself and in the concluding recommendations. The survey summary for each of a num-ber of states begins with the com-ment, “State law does not prohibit [the state’s] county jails from administering medication involuntarily on a nonemergency basis. Therefore, county jails could use a Washington v Harper administrative proceeding to authorize involuntary medication for an inmate who is suffering from a mental disorder, is gravely disabled, or poses a likelihood of serious harm to self or others.”^1(p32) The paragraph concludes with the observation that the mechanisms in place for hospitalization or enforced medication are not used much, if at all, or are not working.

Of the 6 recommendations to address the treatment needs of the seriously mentally ill in jails and prisons, none supports an increase in the number of available beds for seriously mentally ill patients in need of hospital-level treatment. Neither is a recommendation made for measures to expedite hospital transfer. Hospitalization of inmates with mental disorders was entirely overlooked as a potential solution to the unavailability of hospital care.

The first recommendation, foreseen in the Joint Report’s introductory paragraph as well as in how the data were obtained and presented, was: “Provide appropriate treatment for prison and jail inmates with serious mental illness.” Even within the discussion of this recommendation, hospitalization is not mentioned for the seriously and acutely mentally ill, who, were they not incarcerated, would most certainly be hospitalized. Instead, legislation is proposed to allow involuntary medication, and a “model law” patterned after the Washington v Harper² decision is included in the appendix.

The Washington v Harper decision has been generalized to correctional settings, including jails.³ The policy that met constitutional approval in Washington v Harper was a policy specific for the Special Offender Center, the purpose of which was “to diagnose and treat convicted felons with serious mental disorders,”^2(p214) also referred to as a hospital, not the rest of the Washington State Prison System and not for non-medical correctional facilities. No mention of these distinctions was made in the Joint Report. Although the Joint Report has no legal authority whatsoever, it will now most certainly be relied on to support and expand the practice of involuntary medication in jail and prison facilities, thereby further reducing the perceived need for and use of mental hospitalization.

A more fundamental and basic harm than any stigma with or without hospitalization would be the “legitimization” and institutionalization of enforcing medication in a setting whose primary purpose is security and/or punishment, not primacy of the patient, one of several medical ethical tenets that pertain to this issue.⁴ By denying hospitalization to a class of individuals-mentally ill and disabled inmates-that is available to all other individuals with mental illness of the same nature and severity, the detention/correctional system is discriminating based on a status that has nothing to do with need. That such discrimination might be due in part to the more obvious stigma that attaches to indictment or conviction of a criminal offense is secondary in importance to the inferior treatment that is provided certain inmates because of this status.

The Joint Report advocates for a “molecular minimalist” approach to ensure that inmates who refuse medication are treated. As important as antipsychotic medication is in such cases-and it is indeed critically important-this seems to be the only treatment considered. Obviously, a well-staffed and well-programmed hospital offers much more in the way of treatment modalities than medication alone. By advocating only enforced medication within nonmedical correctional facilities, the Joint Report encourages the practice of this type of treatment without other elements that distinguish hospitals from nonmedical correctional facilities. Following this minimalist approach, many severely disturbed inmates will no doubt benefit from receiving the medication that they so desperately need, but they will not have the full array of safety measures and treatment modalities available with hospitalization.

To correctional officers and clinicians, the withdrawal of intensive mental health treatment for severely disturbed inmates can seem inexorable, its restoration impossibly elusive. With hopeless outlook, the urgency of hospitalization yields to the urgency of medication regardless of where it is administered. The failures to be addressed become redefined, no longer as obstacles to hospitalization but as obstacles to involuntary medication alone.

As the practice of involuntary medication in non-medical correctional facilities becomes more widely institutionalized, any political or clinical motivation for restoring hospitalization will continue to fade. Policymakers, correctional administrators, and correctional mental health providers will do what comes naturally: they will justify their actions and, consequently, the newly devolving status quo in correctional health care.

Having bemoaned the transformation of jails and prisons into America’s “new asylums,” the Joint Report strongly supports a practice that will foster the expansion of this devolution into the future with the “molecular minimalist” approach of involuntary medication outside of a hospital with its panoply of programs and treatments. Jails and prisons will continue to devolve and stagnate as warehouses for the mentally ill that provide little more than medication for the most severely, acutely psychotically disturbed inmates.

Disclosures:

Dr Felthous is Professor and Director in the forensic psychiatry division, department of neurology and psychiatry at the Saint Louis University School of Medicine in Saint Louis. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Torrey EF, Zdanowicz MT, Kennard AD, et al. The treatment of persons with mental illness in prisons and jails: a state survey. A Joint Report of the Treatment Advocacy Center and the National Sheriffs’ Association; April 8, 2014. http://tacreports.org/storage/documents/treatment-behind-bars/treatment-behind-bars.pdf. Accessed July 16, 2014.

2. Washington v Harper, 494 US 210 (1990).

3. Felthous AR. The Ninth Circuit’s Loughner decision neglected medically appropriate treatment. J Am Acad Psychiatry Law. 2013;41:105-113.

4. American Medical Association. Code of Medical Ethics. Chicago: American Medical Association Press; 2002.