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Mentally Ill Prisoners in the New Jersey Prison System
Two hundred prisoners filed a class action suit against the New Jersey Department of Corrections (NJDOC) in 1996. A court order issued as a result of that suit mandated an investigation to "assess the mental health services in the... NJDOC with emphasis on those institutions and housing units where the mentally ill were congregated." Inspections were conducted in 1996 and 1997 in Northern State Prison, New Jersey State Prison, and the Edna Mahan Correctional Facility for Women and East Jersey State Prison. Dr. Dennis F. Koson, who conducted the investigation and prepared the report, also visited the Forensic Psychiatric Hospital where mentally ill prisoners in crisis are held.
The report was issued in 1998 and the court case was settled in July 1999. See: D.M. v. Terhune, 67 F.Supp. 2d 401 (DNJ 1999) [PLN, Nov., 2000]. When no information appeared subsequently indicating changes had been made, Human Rights Watch sued to have Koson's report released. When the state still refused to indicate what changes had been made, HRW issued a copy of the report. With this they hoped to pressure the NJDOC and then Governor Christine Whitman to show that conditions had improved. Following are some of the highlights of that report.
" In 1996 the NJDOC contracted with Correctional Medical Services, Inc (CMS) to provide health care to prisoners. CMS, in turn, subcontracted mental health care to Correctional Behavioral Solutions of New Jersey, Inc. (CBS) while maintaining control over medical evaluations, lab studies and medication administration. Many of the serious basic problems found, however, Koson says antedated the privatization of health care services.
" Staffing is described as entirely inadequate, in particular with respect to the number of psychiatrists, far below the bare minimum necessary to treat the number of seriously mentally ill prisoners. The medical health policies instituted by CBS, Koson says are so brief they fail to provide guidance to mental health staff. Mental health records are poorly organized and incomplete.
" There are no facilities providing any degree of privacy for patient doctor communication. Mental health counseling is frequently carried out when the prisoner is inside his or her cell and the staff consultant is outside; it is necessary for each to shout in order for the other to hear. If consultations take place in private areas, prison nurses and prison guards are very often present. Although prisoners in the general population can receive individual therapy, mentally ill prisoners in restrictive custody receive crisis contacts at best. When a prisoner does not speak English as a first language he or she is often without the help of clinicians fluent in his or her language (primarily Spanish, in this case) at times of crisis, i.e., precisely when they are most needed. Koson found that many mentally ill prisoners were not identified as such and therefore lacked access to whatever treatment was possible.
" Medication is often missed because the CBS formulary may not include the most effective medication, or, if part of the formulary, it may have been exhausted; nurses do not check to be sure patients take prescribed medication; monitoring for side effects is minimal; if prisoners are reluctant to take their medications the psychiatrist in charge will often simply cancel them.
Over and over again Koson shows that behavior caused by mental illness - and often beyond the control of the prisoner is treated with disciplinary measures rather than as a medical problem. Because prisoners may not follow institutional rules and regulations, they are often sanctioned at hearings. Those conducting such hearings are often not made aware of the conditions of mentally ill prisoners and hence may be unable to judge behavior that is symptomatic of mental illness. Consequently, mentally ill prisoners are about three times as likely to be in administrative segregation as in the general prison population. Of this situation, Koson says, "Over time incarceration in administrative segregation aggravates mental illness and can cause the onset of mental illness in inmates without a pre-existing condition." Because administrative segregation can cause such deterioration, it is quite likely to lead to further infractions of prison regulations, which in turn mean additional time in segregation. Some prisoners are thus permanently caught in a trap of isolation and deterioration.
Koson was able to review only two of the seventeen suicides that took place during his investigation; nonetheless the charts he reviewed indicated that correctional and nursing staff are not trained to identify and refer suicide risk and that often those placed on observation watch are simply not observed. One of the two suicides had been without his medication for two weeks because the pharmacy had run out; he had filed an unanswered request for mental health treatment; and he was facing immediate transfer. The second had just broken up with his girlfriend; was experiencing withdrawal from drugs; and had just been recaptured after escaping. Though he had been referred for mental health services, he had received none when he committed suicide nearly two days later.
According to Koson, "The treatment of mentally ill inmates in the NJDOC is among the worst I have seen in my 15 years of inspecting correctional systems nationwide. The extensive shortcomings identified in mental health treatment services, the lack of any special facilities for mentally ill inmates, and the harsh disciplinary practices have the net effect of causing significant injury to mentally ill inmates. Almost every record that I have reviewed offers evidence of the misery of mentally ill inmates." Subsequent to HRWs release of the report, an NJDOC statement identified improvements DOC claims to have made among them the institution of mental health units staffed 24 hours a day. The DOC claims to be spending $16 million on mental health care this year and to have budgeted $17.7 million for next year. It would be interesting to read a follow up to Koson's report.
The report was issued in 1998 and the court case was settled in July 1999. See: D.M. v. Terhune, 67 F.Supp. 2d 401 (DNJ 1999) [PLN, Nov., 2000]. When no information appeared subsequently indicating changes had been made, Human Rights Watch sued to have Koson's report released. When the state still refused to indicate what changes had been made, HRW issued a copy of the report. With this they hoped to pressure the NJDOC and then Governor Christine Whitman to show that conditions had improved. Following are some of the highlights of that report.
" In 1996 the NJDOC contracted with Correctional Medical Services, Inc (CMS) to provide health care to prisoners. CMS, in turn, subcontracted mental health care to Correctional Behavioral Solutions of New Jersey, Inc. (CBS) while maintaining control over medical evaluations, lab studies and medication administration. Many of the serious basic problems found, however, Koson says antedated the privatization of health care services.
" Staffing is described as entirely inadequate, in particular with respect to the number of psychiatrists, far below the bare minimum necessary to treat the number of seriously mentally ill prisoners. The medical health policies instituted by CBS, Koson says are so brief they fail to provide guidance to mental health staff. Mental health records are poorly organized and incomplete.
" There are no facilities providing any degree of privacy for patient doctor communication. Mental health counseling is frequently carried out when the prisoner is inside his or her cell and the staff consultant is outside; it is necessary for each to shout in order for the other to hear. If consultations take place in private areas, prison nurses and prison guards are very often present. Although prisoners in the general population can receive individual therapy, mentally ill prisoners in restrictive custody receive crisis contacts at best. When a prisoner does not speak English as a first language he or she is often without the help of clinicians fluent in his or her language (primarily Spanish, in this case) at times of crisis, i.e., precisely when they are most needed. Koson found that many mentally ill prisoners were not identified as such and therefore lacked access to whatever treatment was possible.
" Medication is often missed because the CBS formulary may not include the most effective medication, or, if part of the formulary, it may have been exhausted; nurses do not check to be sure patients take prescribed medication; monitoring for side effects is minimal; if prisoners are reluctant to take their medications the psychiatrist in charge will often simply cancel them.
Over and over again Koson shows that behavior caused by mental illness - and often beyond the control of the prisoner is treated with disciplinary measures rather than as a medical problem. Because prisoners may not follow institutional rules and regulations, they are often sanctioned at hearings. Those conducting such hearings are often not made aware of the conditions of mentally ill prisoners and hence may be unable to judge behavior that is symptomatic of mental illness. Consequently, mentally ill prisoners are about three times as likely to be in administrative segregation as in the general prison population. Of this situation, Koson says, "Over time incarceration in administrative segregation aggravates mental illness and can cause the onset of mental illness in inmates without a pre-existing condition." Because administrative segregation can cause such deterioration, it is quite likely to lead to further infractions of prison regulations, which in turn mean additional time in segregation. Some prisoners are thus permanently caught in a trap of isolation and deterioration.
Koson was able to review only two of the seventeen suicides that took place during his investigation; nonetheless the charts he reviewed indicated that correctional and nursing staff are not trained to identify and refer suicide risk and that often those placed on observation watch are simply not observed. One of the two suicides had been without his medication for two weeks because the pharmacy had run out; he had filed an unanswered request for mental health treatment; and he was facing immediate transfer. The second had just broken up with his girlfriend; was experiencing withdrawal from drugs; and had just been recaptured after escaping. Though he had been referred for mental health services, he had received none when he committed suicide nearly two days later.
According to Koson, "The treatment of mentally ill inmates in the NJDOC is among the worst I have seen in my 15 years of inspecting correctional systems nationwide. The extensive shortcomings identified in mental health treatment services, the lack of any special facilities for mentally ill inmates, and the harsh disciplinary practices have the net effect of causing significant injury to mentally ill inmates. Almost every record that I have reviewed offers evidence of the misery of mentally ill inmates." Subsequent to HRWs release of the report, an NJDOC statement identified improvements DOC claims to have made among them the institution of mental health units staffed 24 hours a day. The DOC claims to be spending $16 million on mental health care this year and to have budgeted $17.7 million for next year. It would be interesting to read a follow up to Koson's report.
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