Shrink Rap News

Report suggests reforms for mentally ill in prison


The Treatment Advocacy Center has released an update of a national survey of prison and jail involuntary treatment policies in its 116-page report, "The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey."

The survey was a replication of a previous study done in 2008. The purpose of the study was to compare treatment bed capacity and the numbers of seriously mentally ill patients housed within a state’s correctional system versus its public mental health system, and to promote the use of involuntary treatment procedures within correctional facilities.

To prepare the report, the center gathered data from each state prison system, as well as from non–randomly selected jails, regarding total bed capacity and the percentage of seriously mentally ill prisoners housed in the correctional system. Information about nonemergency involuntary medication procedures was gathered from prison websites or through Freedom of Information requests. For jails, some policies were obtained or clarified from administrative personnel or mental health professionals within the facility. Information about available psychiatric state hospital beds was gathered from a previous TAC report on state per-capita treatment capacity.

The new report found that the ratio of seriously mentally ill patients housed in correctional facilities versus state hospitals has increased substantially since 2008. Then, the ratio was 3:1. Currently, the ratio is 10 patients held in jail or prison for every single patient in a state hospital. This is clearly a significant change, which TAC attributes to closure of state hospital beds and failure to implement outpatient commitment laws.

As I’ve said in previous columns, I’m reluctant to attribute the incarceration of mentally ill people solely to mental illness. I’m uncomfortable with a reductionist hypothesis that overlooks the whole person. All of my prison patients have challenges common to many non–mentally ill prisoners: substance abuse, lack of social supports, illiteracy, poor vocational skills, and poverty. Psychiatric patients also suffer the baser instincts common to all humanity: fear, greed, and jealous rage. Changes in laws governing sentencing also will affect all offenders, regardless of psychiatric status. Psychiatric medication, voluntary or involuntary, is not the sole answer to the problem of criminality and will do nothing to address these other issues.

Nevertheless, I agree with the majority of the TAC report recommendations, and I applaud the emphasis placed upon expanded use of mental health courts and crisis intervention teams (CIT) to avert incarceration. The recommendation to screen prisoners for mental illness is already mandated by the National Commission on Correctional Health Care (NCCHC) for any accredited facility. According to a 1994 national survey by Dr. Jeffrey L. Metzner and associates, all prisons systems provided either reception or prompt intake mental health screening to all newly admitted intakes (Bull. Am. Acad. Psychiatry Law 1994;22:451-7). Twenty-six percent of the prison systems exceeded screening standards recommended by the American Psychiatric Association. This is good news.

The TAC report also recommended mandatory release planning. Systematic release planning is a challenge to implement for most correctional systems for several reasons. In jail, release may be contingent upon the outcome of a trial and is therefore unpredictable. If the trial is postponed, a valuable community treatment slot is tied up for a patient who will never arrive. Conversely, failure to plan prior to a court date might leave a prisoner on the street directly from court with no aftercare. Nevertheless, states are beginning to realize the cost and public safety benefit of release plans that integrate medical, mental health, and substance abuse services.

One recent outcome study showed that more than half of released prisoners stayed in treatment in the community when an in-reach program provided integrated release planning services, and that annual criminal charges dropped by more than 50% in the year following engagement. More good news.

Finally, a minor quibble. My own state, Maryland, was cited in the report as one of the few states in which the involuntary treatment of inmates is most difficult because of the requirement to transfer the inmate to a hospital first. What the TAC failed to mention was that, in Maryland, the involuntary medication process was substantially undermined by case law. In 2006, the Maryland Court of Appeals decided in Department of Health and Mental Hygiene v. Anthony Kelly that involuntary medication only can be administered if the patient demonstrates dangerousness within the institution. Given this restriction, involuntary medication could not be administered on a nonemergency basis even in a correctional facility.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

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