The criminal justice system is creating a more "severely
disturbed" population of prisoners with mental illness by failing to
provide adequate psychiatric treatment and employing policies that ensure that
these prisoners remain isolated, according to a psychiatrist with expertise in
The number of prisoners with serious mental illness has risen dramatically
as part of a trend that has seen general prison populations increase over the
past couple of decades, said Terry Kupers, M.D., at APA's Institute on
Psychiatric Services in San Diego in October.
In 1999 a report by the Federal Bureau of Prisons found approximately
284,000 inmates in jails and prisons and 500,000 on probation and parole with
a diagnosable mental illness. The proportion of inmates with mental illness
has likely risen since that time, according to Kupers.
Kupers is Institute Professor at the Graduate School of Psychology at
Wright Institute in Berkeley, Calif., and has testified as an expert witness
in class-action lawsuits in more than a dozen states regarding the effects of
imprisonment on inmates with mental illness, the quality of mental health
services in the correctional system, and prison rapes, among other issues.
As prison crowding worsened throughout the 1970s, violence rates escalated,
and prison riots occurred with more regularity. At the same time, correctional
systems were dismantling rehabilitation programs in many states, Kupers said."
Politicians didn't want to appear to be coddling prisoners," he
In 1974 sociologist Robert Martinson, Ph.D., published a study that found
that rehabilitation programs, including those providing education and
psychotherapy, did not reduce recidivism rates of prison inmates.
The findings grabbed headlines, and Congress took note of them too, Kupers
Martinson later acknowledged using dubious methodology in his study and in
1979 recanted his findings, but the later article was largely ignored,
according to Kupers.
Authorities missed a "golden opportunity" to reverse worsening
prison conditions brought on by crowding and a lack of rehabilitation in
subsequent years, Kupers said.
Instead of reducing the prison population by diverting people to mental
health or drug treatment, they began building larger and more secure
In the 1980s, as a way to control inmate crowding and violence, corrections
departments authorized construction of "prisons within prisons,"
as Kupers calls them, or "supermax" prisons.
Each houses many "security" or "segregated" housing
units (SHUs), which are small, well-lit cells in which prisoners spend 23
hours a day (for one hour a day they have access to a small concrete
recreation area). While in the SHU, inmates have virtually no contact with
other people and are allowed few or no belongings.
In people with no history of mental health problems, there is evidence that
time spent in the SHU can lead to anxiety, confusion, violent outbursts, and
even perceptual distortions and hallucinations, according to Kupers, who cited
the work of Stuart Grassian, M.D., a psychiatrist who has studied the effects
of SHUs on prisoners.
In people with serious mental illness, spending time in the SHU exacerbates
symptoms and can lead to psychotic decompensation or suicidality, said Kupers,
who has worked with inmates with mental illness serving time in SHUs in
several states. "These are the most severely psychotic people I have
seen in more than 25 years of practice," he noted.
Depending on the prison, from 25 percent to 50 percent of inmates serving
time in SHUs have some form of mental illness, Kupers said.
Inmates with mental illness are more likely to end up in the SHU because
they may have trouble controlling their tempers or miss social cues that would
enable them to coexist peacefully with fellow inmates, noted Kupers.
They are also more likely to serve longer stints in isolation than inmates
without mental illness.FIG1
Terry Kupers, M.D.: Seriously mentally ill inmates in segregated housing
units "are the most severely psychotic people I have seen in more than
25 years of practice."
Many supermax prisons implement a "phase" system in which
inmates can, with good behavior, move from isolation in the SHU (phase one)
back to the general population, Kupers explained.
Behavioral infractions ranging from cursing to spitting to self-injury earn
the inmate tickets. To move out of phase one, inmates must be ticket-free for
a specified period of time.
Since the effects of isolation often worsen psychiatric symptoms, inmates
with mental illness may have a tendency to act out against themselves or
others, receive additional tickets, and stay in isolation, he noted.
"There are a disproportionate number of people with mental illness in
phase one," Kupers said.
Though these inmates usually receive some form of mental health treatment
while in segregation, the treatment is conducted in front of the cell and
within the sight of inmates in adjoining cells. This makes inmates less likely
to engage in treatment.
Kupers cited instances in which inmates with mental illness accrue time in
segregation that exceeds their original prison terms.
This means that when their original sentence is up, inmates move from total
isolation to the streets. Kupers calls this "maxing out of the
"After we declare that these inmates are too dangerous to live among
the general prison population, we then open the front door of the prison and
let them out onto the streets," which makes little sense, he noted.
Recidivism rates for inmates released from segregation are high.
"They come out very angry, likely to return to substance abuse and
likely to get into trouble and return to prison" where they are sent
immediately to segregated units, he said.
According to Kupers, however, there is a growing recognition of inmates'
mental health needs by governments and departments of correction.
For instance, in January 2003 the New York Supreme Court ruled in Brad
H. et al. v. the City of New York et al. that the city must provide
intensive discharge-planning services for inmates with serious mental
illnesses before they are released.
In addition, a report released earlier this year by the Reentry Policy
Council, a project of the Council of State Governments, outlines hundreds of
recommendations for inmates' successful reentry into society from the criminal
"Reentry [strategies] must build upon the rehabilitation and mental
health treatment that inmates have received during their sentences,"
More information about the Reentry Policy Council and its report"
Charting the Safe and Successful Return of Prisoners to the
Community" is posted at<www.reentrypolicy.org>.▪