Stephen Ragusea’s recent article raised a number of issues about prison mental health care. As a correctional practitioner, I can’t disagree with his analysis, but I would hasten to say this is not a new problem. For decades, numerous authors as well as the federal courts have identified problems about sufficient access to care as well as the quality of correctional mental health services, but fixing the problem has proven more elusive than identifying it.
Based on my experience, this topic endures because we have oversimplified its causes and been hesitant to go where the facts lead us for solutions. For example, limited access to care is not simply the result of clinicians being overwhelmed by the sheer size of the mental health population, although it is a factor. Similarly, poor quality services are not the result of psychologists and academics not trying hard enough to develop innovative practices. These are legitimate issues, but only small pieces of the puzzle.
The larger issues persist because we are reluctant to critically examine the widespread use of segregated housing to manage the mentally ill, and the extent to which that affects our ability to provide sufficient access to quality services for our most at-risk offenders.
Segregation as a Default Solution
For several decades the exploding prison population essentially outpaced the system’s ability to keep up. Out of necessity, administrators relied on segregated housing or special housing units (SHU) to remove and isolate violent, predatory offenders from the population to maintain institution stability. But that poorly nuanced approach quickly evolved into the de facto management solution for almost any problem offender, sweeping up marginally functioning but non-violent mentally ill offenders as well. Even today, anyone who cannot be housed in general population must, by default, go to segregation if or until they can go back to general population. For thousands of chronically mentally ill offenders that can mean months and sometimes years of SHU isolation simply because inpatient psychiatric beds are unavailable and other housing options cannot compete with SHU as an equally viable management alternative.
As the population of mentally ill offenders in SHU grew, the traditional, lock down paradigm came under considerable scrutiny, but even in the face of obvious shortcomings, it persisted relatively unchanged. This is largely due to a shared industry belief that every problem offender needs the high level of security afforded by SHU, regardless of why they were there. While this may be true for violent criminals, it does not have the same universal applicability to most mentally ill offenders who are in prison primarily because they cannot function in society, not because they are criminals.
What’s more, even with little empirical support for the underlying assumptions, the model was replicated time and again, up to and including the proliferation of large supermax facilities. This is despite the fact they are very expensive, labor intensive operations that have always been viewed, even by the correctional industry, as the wrong place to house mentally ill offenders. Nevertheless, in spite of the criticism, the status quo, lock-down philosophy has prevailed creating a self-justifying chicken and egg scenario where building more SHU capacity crowds out resources for other housing options, which in turn necessitates more SHU capacity, etc., etc, etc. Clinicians too are held hostage to the standard SHU routines and must work around the daily unit activities just to have access to offenders to fulfill basic policy requirements. To actually talk with offenders, even mentally ill ones, typically requires jumping more hurdles, such as having staff escorts, competing for minimal interview space or avoiding other time and scheduling conflicts. To compensate, whenever possible clinicians provide services at the door of the offender’s cell, which has become an accepted standard of care for non-crisis SHU contacts. But this is less than ideal because cell front interviews offer little privacy, comfort or opportunity for meaningful involvement. It is insufficient for identifying and/or providing timely intervention for all but the most obviously disordered offenders.
As such, high-risk offenders can go for long periods of time receiving little individual, one-on-one attention unless they experience psychotic episodes or engage in outbursts of violence, self-injury and in some cases attempted suicide. At that point everyone responds to the crisis, but with few permanent housing options other than SHU, any gains are short-lived.
Unequivocally, there are too many mentally ill people in our prisons, but regrettably, that is not likely to change in the near future. At the very least, we must accept that they are here, that they are going to be here, and we must develop the treatment capacity to actually address that reality. We must begin approaching the treatment needs of this population more realistically, as well. We must recognize that this is not a homogeneous group that defies adequate treatment simply because it is so large. Rather, there are many different levels of severity represented in this population that are at very different levels of risk.
The data clearly show SHU houses many members of that at-risk group who account for a disproportionate number of the problems we experience. It is that identifiable, high-risk group almost exclusively housed in SHU that should be the immediate focus of our treatment efforts.
Developing a New Paradigm
The first step in that process is confronting head-on the mindset that the only alternative to general population is segregation.
Once correctional systems begin using SHU more judiciously, they must ensure that the few mentally ill offenders who are placed there are adequately treated according to a realistic standard of care. That standard should not be based on what works best for SHU, but what works best for the offender and what procedural modifications are needed in SHU to guarantee quality care is available. But it is equally unrealistic to insist our only option for managing severely mentally ill offenders is to put them in SHU where they are locked in isolation, seen periodically through the door and often act out before receiving sufficient attention.
In the end, this is a larger societal problem that affects many stakeholders in addition to psychologists and other correctional practitioners. But we can’t simply sit back and wait for society to change while conducting business as usual. We can stop giving tacit approval through our acquiescence and speak out to top level decision-makers in corrections, government and health care about the need for a more nuanced approach to population management and move aggressively to reform the industry’s use of segregation to manage non-violent, mentally ill offenders.