Terry A Kupers M.D.

Prisons and Prisms

Mental Health Jails

A Foolhardy Solution for a Huge Problem

Posted Dec 09, 2017

The population in jails and prisons has multiplied geometrically over the last several decades, and meanwhile the proportion of prisoners suffering from serious mental illness has swelled as well.  A 2014 Report from the National Sheriff’s Association and the Treatment Advocacy Center concluded there are ten times as many individuals with serious mental illness in our jails and prisons as there are in our mental hospitals. There are many reasons for this criminalization of mental illness.  One is the War on Drugs.  Many individuals suffering from serious mental illness are “dually diagnosed” with mental illness and substance abuse.  Then, we have witnessed a decades-long re-institutionalization of individuals with mental illness.  First they were de-institutionalized in the 70s as state hospitals were downsized and closed, then funds for public mental health were incrementally slashed along with funds for other safety net programs, and then many individuals suffering from mental illness fell through the cracks and were locked up.

There are calls in many counties for the construction of “mental health jails,” places inside the correctional system that specialize in managing individuals with mental illness.  But mental health jails are a very wrong solution, on many levels.  To begin, the culture of punishment that prevails in jails is not an appropriate setting for mental health treatment.  A 2015 Human Rights Watch Report exposed a shockingly disproportionate use of excessive force against prisoners with serious mental illness.  Crowding itself has been shown to increase the level of violence in jails and prisons, as well as the prevalence of psychiatric breakdown and suicide.  Of course, advocates for mental health jails claim that they will focus on treatment, but the sad reality is that with subsequent budget cuts for the treatment most of the prisoners in mental health jails will eventually be warehoused in cells with little to do except taking prescribed medications and attending some groups.

But the more significant problem with mental health jails is that a better alternative exists:  Downsize the jails!  Seventy percent of prisoners in jail have not been found guilty of anything, they await trial.  A large proportion will be acquitted.  Most of them do not need to be in jail.  They are there mainly because they cannot afford bail (most defendants who can afford to post bail are released to return to court when the trial begins.)  Meanwhile Behavioral Health Courts have been proven quite safe and effective.  Defendants with mental illness and substance abuse problems are offered a treatment program in the community as an alternative to jail time.  That slightly coercive nudge is enough to help the majority of them adhere to their mental health treatment regimen or complete a substance abuse recovery program in the community. 

There are big problems with mental health jails.  First, it is a jail.  There is a culture of punishment throughout the facility, and that kind of giving orders and punishing refusals is not an appropriate setting for mental health treatment.  The culture of punishment inflicts painful consequences for any infraction of the rules, whereas the entire field of modern psychology is built upon the bedrock notion that positive rewards are much more effective than are punishments for wrong behaviors.     

I am concerned about the exclusive focus on mental health beds being established inside jails!  Often it is a matter of the Sheriff wanting to expand the number of jail beds and grow the corrections budget, and a mental health jail is the trendy guise of new jails today.  But a much more effective and less costly option would be to divert a significant number of prisoners with serious mental illness to non-correctional settings, for example releasing them from jail in spite of the fact they cannot afford bail, or releasing them to mental health and substance abuse treatment programs in the community as alternatives to jail time. 

The clinical literature reflects much better treatment outcomes and much lower recidivism rates for individuals with serious mental illness when they are diverted from jail and treated in the community.  There are many individuals with serious mental illness who could be very safely diverted to non-correctional settings for treatment.  If enough people were diverted, there would be no need for a new or expanded jail of any description. 

References

Torrey, E. Fuller, Mary T. Zdanowicz, Aaron D. Kennard, H. Richard Lamb, Donald F. Eslinger, Michael C. Biasotti, and Doris A. Fuller.  z92014). The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey. A Joint Report of the Treatment Advocacy Center and the National Sherifs’ Association, available at <www.calea.org/sites/default/fles/treatment-behind-barsReport.pdf>.

The 2015 Human Rights Watch Report is

Human Rights Watch. 2015.  Callous and Cruel: Use of Force against Inmates with Mental Disabilities. New York: Human Rights Watch. available at <http://hrw.org/node/134861>