Fifty years ago, America had about 600,000 state hospital beds for individuals suffering mental illnesses. Today, there are fewer than 40,000. In contrast, a Bureau of Justice Statistics study estimated there are approximately 1 million mentally ill individuals in America’s prisons and jails. Consequently, the nation’s largest mental health facilities are no longer psychiatric hospitals but jails: Riker’s Island in New York, the Los Angeles County Jail and the Cook County Jail in Chicago.
Among them, they reportedly house approximately 6,000 mentally ill inmates. While estimates vary depending on the definitions of mental illness, the results of epidemiological surveys over the past decade suggest that 15percent to 50 percent of individuals incarcerated in America’s jails and prisons have symptoms and signs of mental illness, ranging from mild anxiety and depressive disorders to more serious bipolar, depressive and psychotic disorders; many co-morbid with alcohol and/or drug addictions.
Also, inmate suicide risk has become a major concern for correctional facilities.
Three national trends over the past four decades have quietly contributed to this unfortunate state of affairs. First, the deinstitutionalization of the mentally ill from the 1960s through the 1980s followed by reduced community-based mental health resources. Second, the U.S. wars on crime and drugs and subsequent rush to incarcerate, leading to the rapidly increasing growth of jail and prison populations of mentally ill individuals. Third, the general sociopolitical and economic ostracizing of both offenders and the mentally ill.
The fundamental problem behind the scenes is that jails and prisons, currently housing more than 2 million inmates, were not, and still are not, designed to manage and treat mentally ill individuals. These are institutions whose primary social, political and justice responsibilities involve containment and security not treatment.
The evolving side effects of this problem have been three-fold. The first is that, despite the creation of standards of psychological and psychiatric care of prisoners (e.g., the American Correctional Association, the National Commission on Correctional Health Care and the International Association for Correctional and Forensic Psychology) and the efforts of often under-resourced correctional mental health staff, many mentally ill offenders have not been able to receive mental health services sufficient to manage their mental illness, incarcerated or not. For those who do, the services may not be consistent with constitutional, professional or community standards.
Not surprisingly, this has led to occasional ideological and practice conflicts between those whose main responsibility is to treat and those whose main goal is to secure.
This has led to the second result: increased civil litigation against departments of corrections and jails, and at times correctional mental health staff, for inadequately attending to the mental health needs of their mentally ill inmates, and more recently, for failing to provide adequate after-care. Over the past three decades few states have escaped this litigation process and some have received national media attention (e.g., California).
When the courts have deemed it warranted, these departments have been forced to provide better mental health care in keeping with U.S. constitutional mandates, placing additional strains on already stressed public-service and government budgets.
The third result is that many mentally ill prisoners are returned to their communities still mentally ill but often without adequate follow-up care. For the community clinical practitioner, many of these offenders are high risk “no shows” because they often have no health insurance, no job and no ready access to transportation. Many may become non-compliant with treatment because they cannot afford medications and return to street drugs.
Eventually, many are returned to prison because of a new crime or a violation of their parole (e.g., for alcohol or substance abuse). Consequently, the average recidivism rate of mentally ill individuals is often somewhat higher than those who are not. Ironically, their return to jail or prison only contributes to the growing challenges increased numbers of mentally ill inmates pose for correctional facilities, and they may well be later released little better than when they were returned.
And on it goes.
Although well known by those working in the field of correctional mental health, solutions to this unfortunate state of affairs have been difficult to formulate given its scope and often overwhelming cost. Some local jurisdictions have been exploring mental health diversion programs designed to keep mentally ill, less-serious offenders out of jail. But there are yet far too few treatment programs to have a significant impact.
As anyone who looks to on-line resources to further explore this state of affairs will find, none of this is new news; it has been evolving for at least three decades as our society has reshaped its sociopolitical and economic ideology about both the mentally ill and offenders. What one may conclude is that decades ago, a mentally ill individual who offended was first seen as mentally ill and then an offender and might have found treatment in a local mental health facility. The same person today would be first considered an offender then as mentally ill. They would likely not be sent to a local treatment facility; instead they would be incarcerated and, it is hoped, provided a modicum of treatment in a correctional facility.
However, the chances are low. Since this is a large national social problem that has been allowed to foment for years, there is no ready solution in sight. It is likely to continue unless we are willing to relinquish our world leadership position of incarcerating individuals, reshape our thinking about how best to manage crime and drug abuse, deepen our understanding of those variables that contribute to offending and improve management of mentally ill offenders, both while incarcerated and after their return to our communities.
Richard Althouse, Ph.D., is president of the International Association for Correctional and Forensic Psychology. He is a licensed psychologist with 37 years experience in staff and management positions in correctional and forensic mental health settings in Wisconsin. He has published, provided training, provided expert testimony and consultation and lectured at national conferences on a variety of topics, including ethics, standards of practice, suicide intervention and systems analyses of criminal justice policies. He is on the advisory board for the Mental Health in Corrections Consortium, sponsored by the Forest Institute School of Professional Psychology. He can be reached by e-mail at: firstname.lastname@example.org.