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Ill-Equipped: U.S. Prisons and Offenders with Mental Illness

Human Rights Watch, 2003, 215 pp.

Reviewed by Tara Herivel

[In the interests of full disclosure, the author of this review contributed to the following Human Rights Watch Report as a source, and this magazine contributed to the gathering of testimonials for the report.]

It is deplorable that this state's prisons appear to have become a repository for a great number of its mentally ill citizens. Persons who, with psychiatric care, could fit well into society, are instead locked away, to become wards of the state's penal system. Then, in a tragically ironic twist, they may be confined in conditions that nurture, rather than abate, their psychoses."

Judge William Wayne Justice, Ruiz v. Johnson, 37 F. Supp.2d 855 (S.D. Texas, 1999).

Regardless of one's experience or
perspective concerning mental illness in the prison setting, Ill-Equipped, the 2003 report on this topic from Human Rights Watch will outrage and shock. As a one of a kind study (there is scant data on this issue), Ill-Equipped meshes the testimony of prisoners with reports from mental health workers and prison staff, drawing the sobering conclusion that the U.S. presently maintains a de facto policy of warehousing the mentally ill in its prisons with all the expected attendant horror stories. 1 Chapter topics range from inadequate mental health treatment in prisons, to the unique problems of mental illness and women prisoners, to suicide and self-mutilation among mentally ill prisoners.

Ill-Equipped presents critical data regarding rates of mental illness in prison, such as its finding that there are three times more mentally ill people in prison than in mental health hospitals in the U.S., and that prisoners have rates of mental illness two to four times greater than the rates of their non-prisoner counterparts in the general public. It also articulates two of the key reasons for such warehousing: deinstitutionalization of the mentally ill and the concomitant shuttering of public hospitals beginning in the 1960s, and the war on drugs. The result: a tremendous over-representation (conservative estimates hover at around a quarter million mentally ill people in jails and prisons) of people with serious mental illness presently languishing in a special kind of hell in our nation's prisons.

The most powerful stories of Ill-Equipped are those presented by prisoners themselves, who were solicited to write HRW through publications like this magazine to tell their stories. For example, a former prisoner at Muncie's women's prison in Pennsylvania told HRW that at the prison there was "very little mental health care. I was devastated. I hated it there. I saw the psychiatrist every three months and a counselor once in a while. There was nobody to talk to. They told me to go to church _ that that would help me&.I remember trying so hard to remain in contact with reality before they put me back on Haldol. It took a week to see the psychiatrist and get put back on Haldol. They said "you'll just have to wait till he gets to you."

The result for prisoners who go untreated in a system built for punishment is that mentally ill prisoners have much higher rates of suicide and self-mutilation, and are left vulnerable to attacks by other prisoners, or, conversely, other prisoners are left vulnerable to attack by untreated prisoners in the throes of florid bouts of mental illness. Mentally ill prisoners are then infracted, or punished under picayune prison rules, at much higher rates than their non-mentally ill counterparts for such behavior. As a direct result, they wind up spending, on the average, up to a year more time in prison as a result. This is a dark consequence of mental illness in the prison setting that HRW researchers do not fail to highlight.

Take one Illinois prisoner's experience, "H.X." as a typical example of the cycle of misbehavior and discipline that many mentally ill prisoners experience: H.X. is a forty-year-old chronic schizophrenic who has a record of mental illness going back to childhood. According to a complaint filed by Illinois lawyers on behalf of mentally ill prisoners at Tamms prison:

[H.X.] has repeatedly tried to harm himself or his surroundings & on account of his active psychosis, and he has been punished for his actions. For example, twice after he attempted suicide by swallowing a piece of his mirror, he was found guilty of damaging or misusing state property. When guards found him with a homemade rope around his neck attempting to hang himself, they gave him a [disciplinary] ticket for destroying the sheet he had torn to make a rope; the Adjustments Committee found him guilty and ordered him to pay restitution for the torn sheet. Boyd v. Snyder, Amended Complaint, No. 99 C 0056 (N.D. Illinois, February 25, 1999).

While there is a general poverty of understanding regarding mental illness in the free world, in prison it is even worse. HRW advocates for the qualifications, training and competence of prison mental health staff to be equal to community standards. The opposite, however, is the present standard. Always eager to cut costs, prison administrators typically hire under-qualified, thus lower-paid mental health staff, and then dramatically understaff their prisons with these under-qualified workers. Some mental health prison staff would not even be allowed to practice in the free world, their licenses either suspended, or non-existent. For example, Dr. Jeffrey Metzger, an expert in the area of the mental health needs of prisoners, told HRW that in many of the prisons he has visited, unlicensed psychologists are inadequately supervised by licensed practitioners. Metzner added: "I've seen counselors with a B.A. in home economics." Additionally, for-profit companies brought in to deliver correctional mental health services employ licensed clinical directors and fill the rest of the psychologists' and case workers' positions with unlicensed practitioners whom they can pay much less than their licensed counterparts.

The research presented by HRW paints a grim picture; but HRW is careful to balance this dismal scenario with a coherent list of recommendations _ some directed to Congress, some to public officials, community leaders and the general public, and some to prison staff and officials _ that are entirely workable. Suggestions to Congress include: enact the Mentally Ill Offender Treatment and Crime Reduction Act, legislation currently before the U.S. Senate and House of Representatives that would grant funds to communities for diversion programs pre-incarceration; improve access to public benefits covering all needed mental health services; and amend or repeal the Prison Litigation Reform Act, including a recommendation to modify the stringent exhaustion requirements of the Act and to restore attorneys' fees to reasonable levels.

The recommendations for community leaders, public officials and the general public are more general, and include the expected appeals to compassion and reason, like reducing incarceration rates for people with mentally illness and setting higher standards for prison mental health services. More specific recommendations include establishing effective performance reviews of mental health services for prisoners using independent experts and establishing comprehensive internal quality review mechanisms for each prison system and prison.

Recommendations to prison staff and officials essentially boil down to this: hire more staff, make sure they're qualified, provide adequate mental health training for all correctional staff, and don't punish mentally ill prisoners for being mentally ill via disciplinary actions or segregation.

These are entirely workable recommendations _ given the will to apply them _ that both common sense and a general sense of duty to act humanely would demand. Copies of the report are available from Human Rights Watch, 350 Fifth Ave. 34th Fl. New York, NY 10118-3299. It can also be downloaded from the Human Rights Watch website at:


1 HRW researchers focus specifically on mental illness such as mood disorders like bi-polar and serious depression, or psychosis and schizophrenia, and does not include a study of prisoners who have developmental disabilities or organic brain damage. The report also involved only research concerning adult prisoners in the prison setting.

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