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More Mentally Ill in Prison Than in Hospitals
October 22, 2003
Prisons have become the nation’s primary mental health facilities. But for those with serious illnesses, prison can be the worst place to be.
Jamie Fellner Director, U.S. Program of Human Rights Watch

Mentally ill offenders face mistreatment and neglect in many U.S. prisons, Human Rights Watch charged in a report released today.

One in six U.S. prisoners is mentally ill. Many of them suffer from serious illnesses such as schizophrenia, bipolar disorder, and major depression. There are three times as many men and women with mental illness in U.S. prisons as in mental health hospitals.

The rate of mental illness in the prison population is three times higher than in the general population.

According to the 215-page report, Ill-Equipped: U.S. Prisons and Offenders with Mental Illness, prisons are dangerous and damaging places for mentally ill people. Other prisoners victimize and exploit them. Prison staff often punish mentally ill offenders for symptoms of their illness – such as being noisy or refusing orders, or even self-mutilation and attempted suicide. Mentally ill prisoners are more likely than others to end up housed in especially harsh conditions, such as isolation, that can push them over the edge into acute psychosis.

“Prisons have become the nation’s primary mental health facilities,” said Jamie Fellner, director of Human Rights Watch’s U.S. Program and a co-author of the report. “But for those with serious illnesses, prison can be the worst place to be.”

Woefully deficient mental health services in many prisons leave prisoners undertreated – or not treated at all. Across the country, prisoners cannot get appropriate care because of a shortage of qualified staff, lack of facilities, and prison rules that interfere with treatment.

According to Human Rights Watch, the high rate of incarceration of the mentally ill is a consequence of underfunded, disorganized, and fragmented community mental health services. State and local governments have shut down mental health hospitals across the United States, but failed to provide adequate alternatives. Many people with mental illness – particularly those who are poor, homeless, or struggling with substance abuse problems – cannot get mental health treatment. If they commit a crime, even low-level nonviolent offenses, punitive sentencing laws mandate imprisonment.

“Unless you are wealthy, it can be next to impossible to receive mental health services in the community,” said Fellner. “Many prisoners might never have ended up behind bars if publicly funded treatment had been available.”

The Human Rights Watch report is based on more than two years of research and hundreds of interviews with prisoners, corrections officials, mental health experts and attorneys.

It describes prisoners who, because of their illness, rant and rave, babble incoherently, or huddle silently in their cells. They talk to invisible companions, living in worlds constructed of hallucinations. They lash out without provocation, beat their heads against cell walls, cover themselves with feces, mutilate themselves until their bodies are riddled with scars, and attempt suicide.

The Human Rights Watch report documents how prisoners with mental illness are likely to be picked on, physically or sexually abused, and manipulated by other inmates, who call them “bugs.” For example, a prisoner in Georgia, who is both mentally ill and mildly retarded, has been raped repeatedly and exchanges sex for commissary items such as cigarettes and coffee.

Mentally ill prisoners can find it difficult if not impossible to comply with prison rules, and end up with higher than average rates of disciplinary infractions. Security staff – who usually lack training in mental illness – do not distinguish between the prisoner who is disruptive or fails to obey an order because of illness and a prisoner who causes problems for other reasons.

Mentally ill prisoners have been punished for self-mutilating (“destroying state property”); attempting suicide with a torn sheet (“destroying state property”); for yelling and kicking cell doors because of hearing voices (“creating a disturbance”); for throwing papers at a guard while delusional (“battery”); and for smearing feces on the cell door (“being untidy”). Untrained staff escalate confrontations with mentally ill prisoners, sometimes using excessive force. Several mentally ill prisoners have died from asphyxiation after struggling with guards who used improper methods to control them.

Over the past two decades, prison mental health services in the United States have improved – usually because of prisoner litigation. But the surging number of mentally ill men and women entering prison has outrun the availability of services. Public officials have been unwilling to provide the funds necessary to ensure adequate treatment for all the mentally ill offenders who need it.

“Prison officials are being asked to do something they aren’t equipped to do,” said Fellner. “Prisons are designed for punishment, not as places to provide comprehensive mental health treatment. If people with mental illness must be incarcerated, they should be housed in facilities designed and funded to meet their mental health needs.”

Human Rights Watch urged the U.S. Congress to enact legislation proposed by Senator Mike DeWine (R-Ohio) and Congressman Ted Strickland (D-Ohio) that would provide federal grants to divert mentally ill offenders into treatment programs rather than jail or prison, and to improve the quality of mental health services provided to jail and prison inmates.

Human Rights Watch also recommended the use of independent mental health experts to assess mental health services in each prison system, urged elected officials and the heads of correctional agencies to ensure that mentally ill prisoners receive mental health services consistent with community standards of care, and called for rules to prevent housing prisoners with mental illness in isolated confinement or super maximum security prisons.