Prison Punishment Exacerbates Inmates' Psychiatric Illness

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 this area.

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.

Rehabilitation Programs Disappear

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 noted.

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 said.

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 facilities.

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.

Segregation Worsens Behavior Problems

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.

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 SHU.”

“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 justice system.

“Reentry [strategies] must build upon the rehabilitation and mental health treatment that inmates have received during their sentences,” Kupers said.

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>.▪