Some 600 thousand men and women are released from prison in the United States every year.671 There is growing awareness across the country of the high risk of recidivism for prisoners who are not given support services to enable successful re-entry to society. Virtually every mental health expert that Human Rights Watch interviewed acknowledged the particular importance of providing transitional support upon release to those prisoners who are mentally ill. Nevertheless, many states still do not help mentally ill offenders with the discharge reentry process, despite evidence suggesting discharge planning reduces the likelihood that they will return to prison.672 Many mentally ill prisoners who were receiving medication in prison are released with as little as a week’s supply of medicine. Such a limited supply may well not last until they link up with doctors on the outside and are able to get their prescriptions renewed.
According to a Bureau of Justice Statistics study, 34 percent of the adult correctional facilities in the United States do not help released prisoners obtain community mental health services.673 For the 66 percent of facilities nationwide that claim to provide some care to released prisoners with mental health problems, the percentage of mentally ill ex-prisoners who actually receive transitional care is unknown as is the quality of that care.674
The lack of discharge planning and services by prisons for prisoners with mental illness has been taken to the courts. In Wakefield v. Thompson, a federal appeals court considered whether an the Eighth Amendment claim was stated by plaintiff’s allegations that correctional staff at a California prison ignored the instructions of his doctor by refusing to provide him upon his release from prison with the prescribed two-week supply of the psychotropic medication that he took because he suffered from Organic Delusional Disorder.675 The court ruled that state:
A class action lawsuit suit was filed in 1999 by mentally ill inmates in New York City’s jails who challenged the practice of releasing class members without proper provision for treatment or a way to continue their medication. Upon release from jail, mentally ill inmates were provided $1.50 in cash and $3.00 in subway fare. They were not provided any mental health services, government benefits assistance, housing referrals, other services, or help in planning their re-entry. A state supreme court granted an injunction requiring mental health discharge planning.677 It characterized the “irreparable injury” that discharged inmates would face without the injunction as “decompensation for many former inmates, and a return to the cycle of likely harm to themselves and/or others, through substance abuse, mental and physical health deterioration, homelessness, indigence, crime, rearrest, and reincarceration.”678 Under the terms of the settlement, the city agreed to provide mentally ill inmates access to the treatment they need to maintain psychiatric stability after their release, including access to outpatient treatment and medication and the means for pay for those services if the inmate is indigent.679
Absent appropriate mental health treatment (as well as supports for housing, employment and income), the mentally ill who commit criminal offenses are likely to repeat them, cycling in and out of correctional facilities for years. According to the Bureau of Justice Statistics, 81.2 percent of the mentally ill in state prisons have prior criminal histories, 26.3 percent have three to five prior sentences to probation or incarceration, 15.6 percent have six to ten, and 10 percent have eleven or more. Jail inmates who have mental illness have similar criminal histories.680
For all newly discharged offenders, the highest risk of recidivism is in the first six months after release from prison.681 Finding housing and employment, gaining access to public assistance, reuniting with friends and family, and other aspects of making the psychological and physical adjustment to a life outside of prison can present challenges to any former prisoner. Mentally ill offenders who do not receive adequate discharge planning or a continuity of treatment upon release are at a particular disadvantage during this crucial readjustment.682 According to the Council of State Governments:
In a 1985 study in Columbus Ohio, sixty-five patients were followed after their release from state hospitals without discharge planning. Within six months, 32 percent of them had been arrested and jailed, almost all for misdemeanors.684 In New York, 64 percent of mentally ill offenders tracked after release in a 1991 study were rearrested within eighteen months.685 In an Ohio study, 63 percent were rearrested in an eighteen-month period.686 And in Tennessee, the Department of Correction tracked released prisoners with mental health diagnoses for four years after release, and determined that 39 percent were back in the correctional system within twelve months of discharge.687 In addition to the psychological trauma this cycle of reincarceration causes prisoners with mental illness, reincarceration also results in significant financial costs to the defendants and the community.688
Mental health professionals widely recognize that “timely and effective discharge planning is essential to continuity of care and an integral part of adequate mental health treatment.”689 Discharge planning for prisoners with mental illness should include making arrangements to ensure — to the extent possible — the ex-prisoner continues to receive an appropriate level of mental health treatment after release from prison.690 However, among the states that provide some sort of release planning, the extent of arrangements that have been made to connect prisoners with new mental healthcare providers varies widely:
Ideally, a range of support and services should be available to discharged prisoners to facilitate reentry. Equally important, the Consensus Project notes, is successful collaboration between “the various agencies and service providers who will be involved in the release, supervision, support, and treatment of the releasee.”695 These agencies should include, at a minimum, corrections, parole (or releasing authority), mental health, housing, employment, health, and welfare, and private providers of treatment and support services.696 The different agencies should view their individual services as part of an integrated whole, and understand how their mandates overlap, in order to better serve their client populations. This is the goal of Laura Yates, the Social Work Program Director for the North Carolina Department of Correction (DOC). Yates attends meetings of other agencies, making sure that they consider the needs of mentally ill prisoners when they make decisions that affect the service theyprovide. Attending these meetings also helps her to maintain good relationships with other agencies, and to understand how the DOC fits into the larger picture. “Rather than parceling out the components of an individual,” Ms. Yates explains, “we’ve come to a more unified approach to providing services to an inmate.”
Continued access to treatment after incarceration is essential for former prisoners who are mentally ill. Yet, mentally ill prisoners typically leave prison without jobs or other sources of income. Without public assistance, many will not be able to pay for and obtain mental health care.
Unfortunately, many offenders leaving prison encounter substantial delays in gaining access to those public benefits to which they are entitled that would enable them to pay for continued mental health care treatment and support services. For example, although federal law does not preclude states from keeping prisoners on the Medicaid rolls while incarcerated, most, if not all, states remove prisoners and require them to reapply upon release.697 Federal law does require automatic termination of Supplemental Security Income benefits upon incarceration for a period of a year or more, 698 and it requires that Social Security Disability Insurance (SSDI) benefits be suspended, although not terminated, upon incarceration. 699 Other entitlements are also terminated upon incarceration. 700 Such benefits are not automatically reinstated upon a prisoner’s release; it typically takes at least forty-five days and may take as long as eighty-nine days to reactivate these benefits.701 In the interim period, it is difficult for recently discharged mentally ill offenders to maintain a continuity of care.
Recognizing the importance of enabling ex-prisoners to gain immediate access to public benefits, some states have developed mechanisms to accelerate the restoration process, for example, by securing a prisoners’ eligibility for benefits immediately upon release from incarceration. Corrections departments in some states help prisoners fill out benefit applications, although they are prohibited by state law from filing them prior to the date of discharge. Some corrections departments do not help mentally ill prisoners with the process of gaining or regaining public benefits.
Of the states in which prisoners may qualify for medical benefits on the day of discharge, corrections departments cannot guarantee that every prisoner with mental health needs will receive care upon release. As with discharge planning, the success of discharge and transition planning varies significantly from state to state:
Despite the efforts of departments of corrections, not all mentally ill prisoners who leave prison with medical benefits in place are assured an appointment with a treatment provider. For example, although Kansas helps mentally ill prisoners apply for SSI disability insurance before they leave prison, discharged mentally ill offenders in Kansas experience many of the same difficulties in setting appointments with treatment providers as do their counterparts in Tennessee, where the Department of Corrections does not offer such assistance.706 The Kansas DOC tries to set up appointments for prisoners prior to their release dates.707 However, initial after-care appointments can be difficult to obtain. According to Viola Riggins, the Kansas Department of Corrections’ Senior Contract Monitor, the Kansas DOC has a difficult time coordinating its services with county mental health departments. As in Tennessee, recently discharged prisoners in some counties may have to wait between six and twelve weeks to see a mental health professional.708 “The [Kansas] DOC works hard to maintain contracts with county providers,” Ms. Riggins explains, “but some counties are just overwhelmed by the number of mentally ill persons in need of services. In a handful of counties, there never seems to be enough resources to handle the need.”709
Among those states that prohibit incarcerated persons from applying for benefits, some corrections departments help mentally ill prisoners fill out their applications anyway, in preparation for release. A number of state corrections officials are working to change state policy to make prisoners eligible on the date of discharge:
Many states do next to nothing to help incarcerated persons, including the mentally ill, apply for medical benefits prior to their release from prison. Considering that most state Medicaid and SSI offices will not accept applications from incarcerated persons applying for post-release coverage, some corrections departments simply do not view this type of transitional care as part of their job:
Although states have yet to find a seamless way to ensure continuity of mental health coverage and treatment, both are essential to a mentally ill prisoner’s successful reentry into society. Open dialogue and stronger partnerships between state agencies, and between those agencies and community providers, may indeed improve the delivery mechanism for mental health care and increase an offender’s chances of post-release success. In some communities, special programs operate to provide a range of services, including mental health treatment, to ex-offenders with mental illness.
Another client D.E., a drug addict and severe depressive, explained that he:
With states under the burden of an enormous fiscal crisis, looking to cut corners wherever they can, programs for the mentally ill are especially vulnerable. This is short sighted, because the cost of the mentally ill returning to prison is greater in the long run than the cost of providing them adequate transition counseling and treatment upon release. Without good discharge planning and post-release programs, seriously mentally ill prisoners are likely to cycle endlessly between prison and the community, their illnesses worsening, and chances increasing that they will end up in the high security units within the prison system. Successful release plans for the mentally ill include partnerships between departments of corrections and other state agencies, the availability of post-release treatment, early enrollment in Medicaid or another form of health care coverage, and pre-release counseling that begins well before a prisoner’s release.
The proper funding of discharge planning and post-release programs is a crucial public policy issue. In an era in which the United States incarcerates hundreds of thousands of seriously mentally ill men and women in its prisons, it serves neither the mentally ill nor the broader community to shortchange the transitional programs that could serve to break these linkages between mental illness and imprisonment in 21st century America.
671 Paige M. Harrison, and Jennifer C. Karberg, Prison and Jail Inmates at Midyear 2002 (Washington D.C.: Bureau of Justice Statistics, April 2003), table 7.
672See Michael Faenza, Statement on the Criminalization of Mental Illness, National Mental Health Association News Release, September 21, 2000. Available online at: http://www.nmha.org/newsroom/system/news.vw.cfm?do=vw&rid=228, accessed on July 7, 2003.
673 See BJS, Mental Health Treatment in State Prisons, 2000,2001.
674 See Patrick A. Langan, Ph.D. and David J. Levin, Ph.D., Recidivism of Prisoners Released in 1994 (Washington D.C.: U.S. Department of Justice, Bureau of Justice Statistics, June 2002).
675 Wakefield v. Thompson, 177 F.3d 1160 (9th Cir. 1999).
676 Ibid., p. 1164.
677 Brad H. v. City of New York, 712 NYS2d 336 (Supreme Court of New York, 2000).
678 Ibid., p. 345.
679 The settlement and complaint in the case (originally titled Brad H. v. Giuliani) are available on the website of the Urban Justice Center, whose lawyers brought the case. Available online at: http://www.urbanjustice.org/litigation/index.html, under the project heading “mental health,” accessed on September 15, 2003.
680 Ibid., table 6.
682 Council of State Governments, Criminal Justice/Mental Health Consensus Project (New York: Council of State Governments, June 2002).
683 Council of State Governments, Consensus Project (2002), p. 162.
684 E. Fuller Torrey, et al., Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals 54 (1992).
685 Lynette Feder, A Comparison of the Community Adjustment of Mentally Ill Offenders with Those from the General Prison Population (An 18-Month Followup), Law and Human Behavior, vol. 15, no. 5, 1991.
686 Joseph E. Jacoby, Ph.D. and Brenda Kozie-Peak, M.A., The Benefits of Social Support for Mentally Ill Offenders: Prison-to-Community Transitions, Behavioral Sciences and the Law, vol. 15, 1997
687 Unpublished study conducted by the Tennessee Department of Correction, 2003. Human Rights Watch telephone interview with Lenny Lococo, director of mental health services, Tennessee Department of Correction, June 20, 2003.
688 Amici brief of NAMI and the Bazelon Center for Mental Health Law, et al., in Brad H. v. City of New York. Available online at: http://www.bazelon.org/issues/criminalization/bradh.html#4, accessed on September 15, 2003.
689 American Psychiatric Association, Psychiatric Services in Jails and Prisons, 2nd Ed. (Washington D.C., American Psychiatric Association, 2000), p. 18. According to the American Psychiatric Association, discharge planning necessarily includes five essential services: (1) Appointments should be arranged with mental health agencies for all inmates with serious mental illness; (2) Arrangements should be made with local mental health agencies to have prescriptions renewed or evaluated for renewal; (3) Discharge and referral responsibilities should be carried out by specifically designated staff; (4) Inmates should be assessed for the appropriateness of a community referral; and (5) Prison administrative mental health staff should participate in the development of service contracts to ensure access to community-based case managers to provide continuity of service. Ibid., p. 46
690 Amici Brief in Brad H. v. City of New York.
691 Human Rights Watch telephone interview with Dr. Susan Bohn, director of mental health, Nebraska Department of Correctional Services, June 11, 2003.
692 Human Rights Watch telephone interview with Dr. Robert Parker, director of mental health, Arkansas Department of Correction, June 10, 2003.
693 Human Rights Watch telephone interview with Dr. Robin Hulbert, mental health program director, Virginia Department of Corrections, June 11, 2003.
694 Human Rights Watch telephone interview with Laura Yates, social work program director, North Carolina Department of Correction, June 13, 2003.
695 Consensus Project Report, p. 163.
696 Ibid., p. 164.
697 Medicaid is a Federal/State entitlement program that pays for medical assistance for certain individuals and families with low incomes and resources. It was established in 1965 as a cooperative venture jointly funded by the Federal and State governments (including the District of Columbia and the Territories) to assist States in furnishing medical assistance to eligible needy persons. States generally have broad discretion in determining which groups their Medicaid programs will cover and the financial criteria for Medicaid eligibility.
698 Supplemental Security Income (SSI) is a Federal income supplement program funded by general tax revenues. It is designed to help aged, blind, and disabled people, who have little or no income; and it provides cash to meet basic needs for food, clothing, and shelter.
699 Social Security Disability Insurance (SSDI) is an insurance program for persons who have worked long enough--and recently enough--under Social Security to qualify for disability benefits. Most incarcerated persons do not qualify for SSDI.
700 The Sentencing Project, Mentally Ill Offenders in the Criminal Justice System: An Analysis and Prescription (January 2002), p. 14.
701 Amici Brief in Brad H.
702 Human Rights Watch telephone interview with Dr. Joe Fitzpatrick, Director of Mental Health Services, Maine Department of Corrections, June 5, 2003.
703 Human Rights Watch telephone interview with Dr. Robin Hulbert, Virginia Department of Corrections, June 11, 2003.
704 Human Rights Watch telephone interview with Laura Yates, June 13, 2003.
705 Human Rights Watch telephone interview with Viola Riggins, contract monitor for Kansas University, Kansas Department of Corrections, June 12, 2003.
706 Human Rights Watch telephone interview with Viola Riggins, June 12, 2003.
707 According to Viola Riggins, because some releases happen ahead of schedule, either by court order or another mechanism, it is not always possible to schedule appointments prior to release. In some cases, appointments must be scheduled by parole officers.
708 Human Rights Watch telephone interview with Viola Riggins, June 12, 2003.
710 Human Rights Watch telephone interview with Dan Bannish, health service program director, and Pat Ottolini, director of health and addiction services, Connecticut Department of Correction, June 11, 2003.
711 Human Rights Watch telephone interview with Gregory Hughes, mental health regional administrator, Massachusetts Department of Corrections, June 12, 2003.
712 Human Rights Watch telephone interview with Lenny Lococo, director of mental health services, Tennessee Department of Correction, June 20, 2003.
715 Human Rights Watch telephone interview with Dr. Robert Parker, Arkansas Department of Correction, June 10, 2003.
716 Human Rights Watch telephone interview with Dr. Susan Bohn, Nebraska Department of Correctional Services, June 11, 2003
717 Information provided by 6002 staff, including coordinator Melanie Maxwell, and a representative from the King County public mental health system, in a group meeting at the facility, Human Rights Watch interview, Seattle, Washington, August 20, 2002.
718 Human Rights Watch interview with Y.P., Berkeley House, Seattle, Washington, August 20, 2002.
719 Although the 6002 program lost state funding during the writing of this report, in June of 2003, the program was given a 2-year block grant by the Federal Government. Human Rights Watch telephone interview with Declan Finn, director, 6002 Program, July 2, 2003.
720 Human Rights Watch telephone interview with David Stewart, crisis and corrections mental health coordinator, Pierce County, Washington, May 15, 2002.
721 Human Rights Watch interviews with staff, Gaudenzia House, Philadelphia, Pennsylvania, August 13, 2002.
722 Maryland Mental Hygiene Administration Shelter Plus Care Housing Program Annual Report Summary, 2001, p. 2.
723 Human Rights Watch telephone interview with Joan Galece, deputy director, State Department of Mental Health, Maryland, June 7, 2002.
724 Information provided during meeting with Connecticut Department of Correction mental health staff, June 10, 2002.