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“It is deplorable and outrageous 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).

Somewhere between two and three hundred thousand men and women in U.S. prisons suffer from mental disorders, including such serious illnesses as schizophrenia, bipolar disorder, and major depression. An estimated seventy thousand are psychotic on any given day. Yet across the nation, many prison mental health services are woefully deficient, crippled by understaffing, insufficient facilities, and limited programs. All too often seriously ill prisoners receive little or no meaningful treatment. They are neglected, accused of malingering, treated as disciplinary problems.

Without the necessary care, mentally ill prisoners suffer painful symptoms and their conditions can deteriorate. They are afflicted with delusions and hallucinations, debilitating fears, extreme and uncontrollable mood swings. They huddle silently in their cells, mumble incoherently, or yell incessantly. They refuse to obey orders or lash out without apparent provocation. They beat their heads against cell walls, smear themselves with feces, self-mutilate, and commit suicide.

Prisons were never intended as facilities for the mentally ill, yet that is one of their primary roles today. Many of the men and women who cannot get mental health treatment in the community are swept into the criminal justice system after they commit a crime. In the United States, there are three times more mentally ill people in prisons than in mental health hospitals, and prisoners have rates of mental illness that are two to four times greater than the rates of members of the general public. While there has been extensive documentation of the growing presence of the mentally ill in prison, little has been written about their fate behind bars.

Drawing on interviews with correctional officials, mental health experts, prisoners and lawyers, this report seeks to illuminate that fate. We identify the mentally ill in prison — their numbers, the nature of their illnesses, and the reasons for their incarceration. We set out the international human rights and U.S. constitutional framework against which their treatment should be assessed. We review their access to mental health services and the treatment they receive. We examine the various levels of care available to them; their confinement in long-term segregation facilities; the way prisons respond to their self-mutilation and suicide attempts; and the services they receive upon release from prison.

Our research reveals significant advances in mental health care services in some prison systems. Across the country there are competent and committed mental health professionals who struggle to provide good mental health services to those who need them. They face, however, daunting obstacles - including facilities and rules designed for punishment. The current fiscal crisis in states across the country also threatens the gains that have been made.

Our research also indicates the persistence in many prisons of deep-rooted patterns of neglect, mistreatment, and even cavalier disregard for the well-being of vulnerable and sick human beings. A federal district judge, referring in 1999 to conditions in Texas’ prisons, made an observation that is still too widely applicable:

Whether because of a lack of resources, a misconception of the reality of psychological pain, the inherent callousness of the bureaucracy, or officials’ blind faith in their own policies, the [corrections department] has knowingly turned its back on this most needy segment of its population.1

In the most extreme cases, conditions are truly horrific: mentally ill prisoners locked in segregation with no treatment at all; confined in filthy and beastly hot cells; left for days covered in feces they have smeared over their bodies; taunted, abused, or ignored by prison staff; given so little water during summer heat waves that they drink from their toilet bowls. A prison expert recentlydescribed one prison unit as “medieval…cramped, unventilated, unsanitary…it will make some men mad and mad men madder.” Suicidal prisoners are left naked and unattended for days on end in barren, cold observation cells. Poorly trained correctional officers have accidentally asphyxiated mentally ill prisoners whom they were trying to restrain.

Offenders who need psychiatric interventions for their mental illness should be held in secure facilities if they have committed serious crimes, but those facilities should be designed and operated to meet treatment needs. Society gains little from incarcerating offenders with mental illness in environments that are, at best, counter-therapeutic and, at worst dangerous to their mental and physical well-being. As another federal judge eloquently noted:

All humans are composed of more than flesh and bone — even those who, because of unlawful and deviant behavior, must be locked away…. Mental health, just as much as physical health, is a mainstay of life. Indeed, it is beyond any serious dispute that mental health is a need as essential to a meaningful human existence as other basic physical demands our bodies may make for shelter, warmth, or sanitation.2

Doing time in prison is hard for everyone. Prisons are tense and overcrowded facilities in which all prisoners struggle to maintain their self-respect and emotional equilibrium despite violence, exploitation, extortion, and lack of privacy; stark limitations on family and community contacts; and a paucity of opportunities for meaningful education, work, or other productive activities. But doing time in prison is particularly difficult for prisoners with mental illness that impairs their thinking, emotional responses, and ability to cope. They have unique needs for special programs, facilities, and extensive and varied health services. Compared to other prisoners, moreover, prisoners with mental illness also are more likely to be exploited and victimized by other inmates.

Mental illness impairs prisoners’ ability to cope with the extraordinary stresses of prison and to follow the rules of a regimented life predicated on obedience and punishment for infractions. These prisoners are less likely to be able to follow correctional rules. Their misconduct is punished — regardless of whether it results from their mental illness. Even their acts of self-mutilation and suicide attempts are too often seen as “malingering” and punished as rule violations. As a result, mentally ill prisoners can accumulate extensive disciplinary histories.

Our research suggests that few prisons accommodate their mental health needs. Security staff typically view mentally ill prisoners as difficult and disruptive, and place them in barren high-security solitary confinement units. The lack of human interaction and the limited mental stimulus of twenty-four-hour-a-day life in small, sometimes windowless segregation cells, coupled with the absence of adequate mental health services, dramatically aggravates the suffering of the mentally ill. Some deteriorate so severely that they must be removed to hospitals for acute psychiatric care. But after being stabilized, they are then returned to the same segregation conditions where the cycle of decompensation begins again.3 The penal network is thus not only serving as a warehouse for the mentally ill, but, by relying on extremely restrictive housing for mentally ill prisoners, it is acting as an incubator for worse illness and psychiatric breakdowns.

International human rights law and standards specifically address conditions of confinement, including the treatment of mentally ill prisoners. If, for example, U.S. officials honored in practice the International Covenant on Civil and Political Rights, to which the United States is a party, and the United Nation’s Standard Minimum Rules for the Treatment of Prisoners, which sets out detailed guidelines on how prisoners should be treated, practices in American prisons would improve dramatically. These human rights documents affirm the right of prisoners not to be subjected to cruel, inhuman, or degrading conditions of confinement and the right to mental health treatment consistent with community standards of care. That is, human rights standards do not permit corrections agencies to ignore or undertreat mental illness just because a person is incarcerated. The Eighth Amendment to the U.S. Constitution, which prohibits cruel and unusual punishment, also provides prisoners a right to humane conditions of confinement, including mental health services for serious illnesses.

Prisoners are not, however, a powerful public constituency, and legislative and executive branch officials typically ignore their rights absent litigation or the threat of litigation. U.S. reservations to international human rights treaties mean that prisoners cannot bring suit based on violations of their rights under those treaties. Lawsuits under the U.S. Constitution can only accomplish so much. Federal courts have interpreted the U.S. Constitution as violated only when officials are “deliberately indifferent” to prisoners’ known and serious mental health needs. Neglect or malpractice are not constitutional violations. In most states, prisoners cannot sue public officials under state law for medical malpractice. Finally, the misguided Prison Litigation Reform Act, enacted in 1996, has seriously hampered the ability of prisoners to achieve effective and timely help from the courts.

Mental health treatment can help some people recover from their illness, and for many others it can alleviate its painful symptoms. It can enhance independent functioning and encourage the development of more effective internal controls. In the context of prisons, mental health services play an even broader role. By helping individual prisoners regain health and improve coping skills, they promote safety and order within the prison community as well as offer the prospect of enhancing community safety when the offenders are ultimately released.

The components of quality, comprehensive mental health care in prison are well known. They include systematic screening and evaluation for mental illness; mechanisms to provide prisoners with prompt access to mental health personnel and services; mental health treatment that includes a range of appropriate therapeutic interventions including, but not limited to, appropriate medication; a spectrum of levels of care including acute inpatient care and hospitalization, long-term intermediate care programs, and outpatient care; a sufficient number of qualified mental health professionals to develop individualized treatment plans and to implement such plans for all prisoners suffering from serious mental disorders; maintenance of adequate and confidential clinical records and the use of such records to ensure continuity of care as prisoners are transferred from jail to prison and between prisons; suicide prevention protocols for identifying and treating suicidal prisoners; and discharge planning that will provide mentally-ill prisoners with access to needed mental health and other support services upon their release from prison. Peer review and quality assurance programs help ensure that proper policies on paper are translated into practice inside the prisons.

Many prison systems have good policies on paper, but implementation can lag far behind. In recent years, some prison systems have begun to implement system-wide reforms - often prompted by litigation - and innovative programs to attend to the mentally ill. Nevertheless, across the country, seriously ill prisoners continue to confront a paucity of qualified staff who can evaluate their illness, develop and implement treatment plans, and monitor their conditions; they confront treatment that consists of little more than medication or no treatment at all; they remain at unnecessarily high risk for suicide and self-mutilation; they live in the chaos of the general prison population4 or under the strictures of solitary confinement - with brief breaks in a hospital - because of the lack of specialized facilities that would provide the long-term supportive, therapeutically-oriented environment they need.

Providing mental health services to incarcerated offenders is frustrated by lack of resources. It is also frustrated by the realities of prison life. Correctional mental health professionals work in facilities run by security staff according to rules never designed for or intended to accommodate the mentally ill. For example, mentally ill prisoners are consigned to segregated units even though the harsh, isolated confinement in such units can provoke psychiatric breakdown. Moreover, the rules designed by security staff for prisoners in solitary confinement prevent mental health professionals from providing little more than medication to the mentally ill confined in these units; they cannot provide much needed private counseling, group therapy, and structured activities. Correctional staff who have the most contact with prisoners and who are often called upon to make decisions regarding their needs — particularly in the evenings when mental health staff are not present — often lack the training to recognize symptoms of mental illness and to handle appropriately prisoners who are psychotic or acting in bizarre or even violent ways. It is easy for untrained correctional staff to assume an offender is deliberately breaking the rules or is faking symptoms of illness for secondary gain, such as to obtain a release from solitary confinement into a less harsh hospital setting.

Many experts with whom we spoke also noted that, unfortunately, the judgment of some mental health professionals working in prisons becomes compromised over time. They become quick to find malingering instead of illness; to see mentally ill prisoners as troublemakers instead of persons who may be difficult but are nonetheless deserving of serious medical attention. The tendency to limit treatment to the most acutely and patently ill is also encouraged by the lack of resources; since everyone cannot receive appropriate treatment, mental health staff limit their attention to only a few.

* * *

The growing number of mentally ill persons who are incarcerated in the United States is an unintended consequence of two distinct public policies adopted over the last thirty years.

First, elected officials have failed to provide adequate funding, support, and direction for the community mental health systems that were supposed to replace the mental health hospitals shut down as part of the “deinstitutionalization” effort that began in the 1960s.

A federal advisory commission appointed by President George W. Bush, the President’s New Freedom Commission on Mental Health, recently reported that the U.S. mental health system was “in shambles.” People with serious mental illnesses — particularly those who are also poor, homeless, and suffering as well from untreated alcoholism or drug addiction — often cannot obtain the mental health treatment they need. Left untreated and unstable, they enter the criminal justice system when they break the law. Most of their crimes are minor public order or nuisance crimes, but some are felonies which lead to prison sentences.

Second, elected officials have embraced a punitive anti-crime effort, including a national “war on drugs” that dramatically expanded the number of persons brought into the criminal justice system, the number of prison sentences given even for nonviolent crimes (particularly drug and property offenses), and the length of those sentences. Prison and jail populations have soared, more than quadrupling in the last thirty years. A considerable proportion of that soaring prison population consists of the mentally ill.

There is growing recognition in the United States that the country can ill-afford its burgeoning prison population, and that for many crimes, public goals of safety and crime reduction would be equally — if not better — served by alternatives to incarceration, including drug and mental health treatment programs. Momentum is building, albeit slowly, to divert low-level nonviolent offenders from prison — an effort that would benefit many of the mentally ill. But until the country makes radical changes in its approach to community mental health — as well as poverty and homelessness — there is every likelihood that men and women with mental illness will continue to be over-represented among prison populations.

Corrections officials recognize the challenge posed to their work by the large and growing number of prisoners with mental illness. They recognize they are being asked to serve a function for which they are ill equipped. Most of what we say in this report will not be new to them. We hope our report, and the extensive documentation of human suffering that it contains, will support their efforts to ensure appropriate conditions of confinement and mental health services for the mentally ill men and women consigned to them. We hope it helps marshal political sentiments and public opinion to understand the need for enhanced mental health resources — for those in as well as outside of prison. We also hope it encourages dramatic changes in the use of prisons in the United States — reserving them for dangerous violent offenders who must be securely confined and not for low-level nonviolent offenders. The problems we document in this report can be solved — but to do so requires drastically more public commitment, compassion, and common sense than have been shown to date.

The Scope of this Report

We are keenly aware of the many related problems that we have excluded from this report. Our inquiry is limited to adults, although a high percentage of youth in the juvenile justice system are also mentally ill. We concentrate on mental illness, while recognizing that prisoners who are developmentally disabled or suffer from organic brain damage also face unique and important problems. And our inquiry is limited to prisons, although we acknowledge — as all who are familiar with jails must — that jails are equally, if not more, overwhelmed by mentally ill prisoners for whom they are ill-equipped to care.

There are approximately fourteen hundred adult prisons in the United States, operated by or responsible to fifty state correctional agencies and the federal bureau of prisons. We have not attempted to produce a comprehensive assessment of the treatment of mentally ill prisoners in any one of these prisons or prison systems. Nor have we sought to identify those that deserve praise for the progress they have made in providing mental health services. Rather, we have sought to identify widely, albeit not universally, shared problems and to present illustrative examples. The time period covered in this report is from the mid-1990s to the present. Examples of specific problems in individual prisons presented in this report may have been subsequently addressed by correctional authorities, and, where we are aware of such remedial measures, we have described them.

A Note on Methodology

This report is based on research, interviews, and visits to numerous correctional facilities conducted primarily between 2001 and 2003, although we visited some prisons in earlier years. Human Rights Watch interviewed and/or corresponded with at least three hundred prisoners, mental health experts, prison officials, and lawyers from many parts of the country. We have visited prisons and conducted in-person, on-site interviews with prisoners and staff in California, Colorado, Connecticut, Illinois, Indiana, Minnesota, New York, Ohio, Oklahoma, Pennsylvania, Texas, Vermont, and Washington. We also interviewed by telephone many correctional staff, including mental health professionals, in a number of states whose facilities we did not visit. In the course of our research, we have consulted experts in numerous fields, including psychiatry, psychology, bio-statistics, law, correctional security classifications, prison architecture, suicide protocols, prison mental health care, public health care, community mental health, counseling, and substance abuse treatment. We have also drawn on many other resources, including opinions generated in court rulings; information gathered by court monitors as well as experts hired for court challenges to prison mental health services; academic and professional writing on correctional mental health issues; and unpublished studies.

Prisoners were contacted through advertisements placed in Prison Legal News asking seriously mentally-ill prisoners to write to Human Rights Watch, through attorneys who had been involved in litigating cases on mental illness in prisons, through family members who believed their incarcerated relatives needed mental health help that they were not receiving, and through organizations such as state protection and advocacy groups.5 The staff at many of the institutions Human Rights Watch visited while researching this report also agreed to provide us access, with prisoner consent, to individuals randomly selected from the mental health caseload and prisoners whose behavior and correctional histories met Human Rights Watch research criteria. Throughout this report, we provide extracts from letters prisoners with mental illness sent us. We have not sought to verify the specific allegations made in them and recognize that some may be embellished or altered in the telling. Nevertheless, the letters are eloquent testimony to the prisoners’ sense of their experience. Where prisoners’ letters are quoted, we have left in place spelling and grammatical errors.

It is impossible to do justice to the wealth of information accumulated during research for this report without creating a publication that was thousands of pages in length. Yet, because prisons operate in secret, for the most part, it is important for the public to have access to as much material as is possible. We have placed some of the expert reports produced during litigation on our website, as they are not readily available to the public, and reveal, in often harrowing detail, problems with specific prisons regarding the treatment of mentally ill offenders. They can be found at

1 Ruiz v. Johnson, 37 F.Supp. 2d 855, 914 (S.D. Texas, 1999), rev’d 178 F.3d 385 (5th Cir. Tex., 1999), adhered to on remand, 243 F.3d 941 (5th Cir. Tex., 2001).

2 Madrid v. Gomez, 889 F. Supp. 1146, 1261 (N.D. California, 1995).

3 Decompensation refers to the aggravation of symptoms of mental illness leading to a marked deterioration from previously adequate levels of functioning and coping in daily life.

4 Prisoner’s are part of the “general population” of a prison unless they have been placed in segregated or special housing units for such purposes as discipline, protective custody, security, or medical care.

5 In recent years, an increasing number of protection and advocacy groups, including NAMI (formerly known as the National Alliance for the Mentally Ill) have begun focusing on the issue of the mentally ill in prison.

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October 2003