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“I am a commander of Star Wars SS. We have been practicing nuclear allimators stronger than the Russians. If I’m killed it’s going to burn stars and the world at the same time. If we don’t watch it, people will burn and I will go into a different dimension. So I’d like to keep my single cell as long as possible. I write to Berlin, to Red China, they don’t send me no package.”71

- D.O.T., California State Prison, Corcoran.

The mentally ill in prison, as in the world outside prison, suffer from a wide array of mental disorders serious enough to require psychiatric treatment. The symptoms of some prisoners with serious mental illness are subtle, discernable only by clinicians. This is particularly true for prisoners suffering serious depression, who may just appear withdrawn and unsociable to other prisoners and staff. But the serious mental illness of some prisoners is easily identified even by the layman: they rub feces on themselves, stick pencils in their penises, bite chunks of flesh from their bodies, slash themselves, hallucinate, rant and rave, mumble incoherently, stare fixedly at the walls. While many of the mentally ill in prison do not suffer major impairments in their ability to function, some, like the above-quoted prisoner, are so sick they live in a world entirely constructed around their delusions.

Not only is the number of prisoners with mental illness growing, but more persons are being incarcerated whose illnesses fall at the most severe end of the mental illness spectrum. According to Dave Munson, lead psychologist at Washington State’s McNeil Island Correctional Center, “the severity of the mental illness of those coming in is increasing. People are no longer going to state hospitals. The prisoners often have no idea how they ended up here.”72 In Oregon, the administrator for counseling and treatment services reported that in the last five years the prison system has begun receiving prisoners who have been in mental health group homes since childhood.73 Gloria Henry, warden of Valley State Prison for Women, California’s largest prison for female prisoners, also points to the severity of the mental conditions of incarcerated women:

I don’t know how [some of these women] were sentenced to prison. They have no understanding of why they are in prison. I don’t know what purpose it serves. To some degree the services will be limited, because this is a prison, not a state hospital. We’re having to adjust and make changes to accommodate mental health — and it’s difficult.74

Overview of Mental Illness

Mental disorders include a broad range of impairments of thought, mood, and behavior. The degree of impairment can vary dramatically from individual to individual. Also, some individuals with mental illness have periods of relative stability during which symptoms are minimal, interspersed with incidents of psychiatric crisis. Other individuals are acutely ill and dramatically symptomatic for prolonged periods.

In this report, we use the term serious mental illness to refer to diagnosable mental, behavioral, or emotional disorders of sufficient duration to meet diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, (generally referred to as DSM-IV)75 and that result in substantial interference with or limitations on one or more major life activities.76 The DSM-IV defines a mental disorder as:

a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g. a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom.77

The DSM-IV classification for mental disorders includes serious mental illness (Axis 1) and serious personality disorders (Axis 2). In prisons, the category of serious mental illness is typically limited to such conditions as schizophrenia, serious depression, and bipolar disorder. Schizophrenia is a frightening, complex, difficult, and debilitating disease which may include disordered thinking or speech, delusions (fixed, rigid beliefs that have no basis in reality), hallucinations (hearing or seeing things that are not real), inappropriate emotions, confusion, withdrawal, and inattention to any personal grooming. Among the subtypes of schizophrenia is “paranoid schizophrenia” with characteristics of delusions of persecution and extreme suspiciousness. Even if a person with schizophrenia is described as recovered or in remission, quite likely he or she is neither ill nor well, but will usually have a great deal of difficulty adjusting to life situations, and can be driven over the edge by overwhelming demands.78 Serious or clinical depression, which can be experienced episodically or chronically, usually includes, among other symptoms, profound feelings of sadness, helplessness, and hopelessness. It can also be accompanied by psychotic features, including hallucinations and/or delusions. Clinical depression, which is far more common among women than men, is a significant suicide risk factor. Bipolar disorder (previously called manic-depressive disorder) is characterized by frequently dramatic mood swings from depressions to mania. During manic phases some people may be psychotic and may experience delusions or hallucinations.

Wholly apart from ensuring adequate mental health treatment, the incarceration of thousands of persons with these illnesses poses extremely difficult management challenges for correctional staff trying to ensure prison safety and security. For example, serious depression puts people at risk of suicide. Persons with schizophrenia may experience prison as a peculiarly frightening, threatening environment that can result in inappropriate behavior including self-harm or violence directed toward staff or other prisoners. Persons with bipolar disorder in a manic phase can be disruptive, quick to anger, provocative, and dangerous.79 Prisoners with serious mental illness, particularly if the illness has psychotic features, may find it next-to-impossible to abide by, or, in more extreme cases, even to understand, prison regulations. According to correctional mental health expert and clinical professor of psychiatry at the University of Colorado’s Health Sciences Center Dr. Jeffrey Metzner, “A small percentage [of prisoners] don’t understand the rules. They’re the ones who are psychotic. More common is that prison rules don’t mean much to someone hearing voices — that’s the least of their problems.” A person with paranoid schizophrenia, said Metzner, may, on a literal level, understand a rule but nevertheless view a request to abide by that rule as being part of a conspiracy directed against him. “It’s less of not understanding and more of acting on distortions.”80

It is not uncommon for persons who end up in jail or prison to have Axis 2 personality disorders which result in serious problems in thinking, feeling, interpersonal relations, and impulse control. When these disorders are associated with significant functional impairments they constitute serious mental illnesses. According to the DSM-IV, personality disorders are “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”81

Perhaps the most prevalent personality disorders among jail and prison inmates are anti-social personality disorder (ASPD) and borderline personality disorder. The essential feature of the former is “a pervasive pattern of disregard for, and violation of, the rights of others.”82 Persons with antisocial personality disorder, typically men, can be particularly difficult to manage in a correctional setting. They can often be manipulative, volatile, disruptive, and likely to engage in aggressive, impulsive “acting out” behavior which can include assaults on others, self-mutilation and/or suicide attempts. Epidemiological research shows that only 15 percent to 20 percent of prisoners have bona fide ASPD, if the diagnosis is made using the criteria in the DSM-IV. Yet, according to psychiatrist Dr. Terry Kupers, who has examined mental health services in many prisons, correctional mental health staff have a tendency to over-diagnose the presence of ASPD, essentially using it as a default diagnosis for anyone who seems to have mental problems of some sort but does not have an obvious Axis I illness. A diagnosis of ASPD becomes, in fact, a moral rather than clinical judgment; prisoners with APSD are “bad” not “mad.”83

According to the DSM-IV, borderline personality disorder is marked by “patterns of instability in interpersonal relationships, self-image and affects, and marked impulsivity that begins in early adulthood.” People with borderline personality disorder often have volatile and extreme emotions, are prone to depression, and can be difficult and manipulative. Many resort to self-mutilation at some point. Borderline personality disorder can also include episodes of psychotic decompensation. Research suggests that childhood trauma — particularly sexual and physical abuse — is one of the causal factors for the disorder. About 70 to 77 percent of people diagnosed with this disorder are women.84 Some psychiatrists, such as Harvard University’s Dr. Judith Herman, believe that many, if not most, women diagnosed as borderline are in fact suffering from what Herman calls, “complex posttraumatic stress disorder.” The multiple traumas cause psychological disorganization and emotional dyscontrol that look very much like borderline personality disorder. If the diagnosis, however, is of borderline personality disorder, the complex posttraumatic stress disorder is ignored and, all too often, the women are considered just plain difficult and not amenable to or in need of treatment.85

Although people with personality disorders may appear “normal” — just obnoxious or difficult — these mental disorders are very real and drive those who have them to behave the way they do. Unlike Axis 1 mental illnesses, personality disorders are not believed to be caused by abnormality of brain chemistry or other organic problems, but are rooted in life histories, such as childhood traumas and neglect, and perhaps genetics. For that reason, they do not generally respond to medications and are thus harder to treat and contain. Personality disorders can and often do co-exist with Axis-1 mental illnesses, further complicating the diagnosis and treatment of both.

It is a convention in correctional psychiatry to identify as serious mental illnesses only certain serious Axis I disorders such as bipolar disorder, major depression, and schizophrenia, and to limit mental health treatment to prisoners with those disorders. It is a convention in part created by the shortage of mental health staff: absent sufficient numbers to treat everyone, the determination of who warrants treatment is restricted to the most deeply troubled individuals and also those who are more likely to respond to the primary treatment modality offered in prison — medication. Correctional mental health staff are particularly reluctant to expend treatment time on prisoners with personality disorders. The judgment of correctional mental health staff about the seriousness of a non-psychotic mental condition may also be colored by their concerns that prisoners may be malingering or seeking secondary gains. It is also a convention that survives under constitutional jurisprudence that has failed to clarify the boundaries of the “serious mental illness” for which mental health services are required.

Nevertheless, individuals who suffer from other illnesses not on the short list of Axis I disorders can be equally distressed and disabled. Some personality disorders can include episodes of psychotic decompensation and several of the personality disorders can result in severe disability. For example, an individual suffering from a severe generalized anxiety disorder with panic attacks might spend all of her time terrified, incapable of acting productively, and cringing in her cell. Someone with severe obsessive-compulsive disorder might spend all his time cleaning his cell or counting cracks in the wall and be completely incapable of undertaking other activities. A person with a dysthymic disorder (a less severe form of depression than a major depressive disorder) might successfully commit suicide.

Failure to diagnose and properly attend to prisoners’ personality disorders can lead to inappropriate responses by correctional staff that aggravate the prisoners’ conduct and heighten the incidence of self-mutilation and suicide attempts. The clinical diagnosis of personality disorders should be followed with useful therapeutic interventions, such as individual and group talk therapy and cognitive skills and anger management training. Medication cannot address the fundamentals of personality disorders but can alleviate frequently concomitant symptoms, such as depression and anxiety. Mental health interventions can not only make life in prison more tolerable both for the prisoners and the staff who have to deal with them; they also can provide the prisoners with life-skills — such as personal hygiene, education, anger management, and an ability to recognize the signs of an approaching mental health crisis — that will serve them well when they are released from prison.

Examples of Mentally Ill Prisoners

To provide a sense of the nature and degree of serious mental illness from which some prisoners suffer, we note below some descriptions, many of which were made by mental health experts and courts who had access to complete mental health records:

  • “Prisoner 1 is a 25-year-old who was transferred to [Wisconsin’s] Supermax in February 2001. He has a history of serious mental illness beginning at age 11. According to a [1995] entry in his clinical file…he was diagnosed with Paranoid Schizophrenia. Prisoner 1 experiences command hallucinations, which are voices that tell him to do bad things. Prisoner 1’s charts list medication orders dating back to 1995 that include the antipsychotic medications Thorazine, Haldol, Quetiapine, Seroquel, Loxitane, Risperdal and Olanzopoine. On the Mental Illness Screening Tool in his file, Prisoner 1 was assigned a diagnosis of “Chronic paranoid Schizophrenia vs. Major Depression with Psychotic Features.” Prisoner 1 told Dr. Kupers [plaintiffs’ expert] that he hears voices constantly that command him to kill himself or hurt others….Prisoner 1 told Kupers that he cannot sleep because he “sees things,” including “demons moving around the floor and climbing on my bed” all night. Prisoner 1 told Kupers that he has paranoid thoughts that the guards are out to get him. He paces in his cell. Prisoner 1 continues to experience auditory hallucinations and massive anxiety despite his strong psychotropic medications…86

  • Psychologist Craig Haney painted a harrowing picture of some of the prisoners with mental illness he encountered in Texas prisons:

  • I'm talking about forms of behavior that are easily recognizable and that are stark in nature when you see them, when you look at them, when you're exposed to them. In a number of instances, there were people who had smeared themselves with feces. In other instances, there were people who had urinated in their cells, and the urine was on the floor…. There were many people who were incoherent when I attempted to talk to them, babbling, sometimes shrieking, other people who appeared to be full of fury and anger and rage and were, in some instances, banging their hands on the side of the wall and yelling and screaming, other people who appeared to be simply disheveled, withdrawn and out of contact with the circumstances or surroundings. Some of them would be huddled in the back corner of the cell and appeared incommunicative when I attempted to speak with them. Again, these were not subtle diagnostic issues. These were people who appeared to be in profound states of distress and pain.87

  • [A Texas prisoner was]…a 45 year old man with chronic paranoid schizophrenia found in a decompensated psychotic state. His thinking was grossly disorganized and his speech was irrelevant. He appeared confused, agitated, and paranoid. The medical record indicated that his antipsychotic medication had been discontinued…due to refusals. There could be no question that his decompensation was long and tortured…. A 28 year old man with schizoaffective disorder and mental retardation…he appeared floridly psychotic and deteriorating. His left arm was severely mutilated from multiple self-inflicted lacerations.88

  • “John Doe #117 was charged with ‘being untidy’ because he smeared feces on his cell door…[A] psychological report found that John Doe #117 was ‘mentally limited and often psychotic…not able to control his behavior and…not in good touch with reality’…[A subsequent psychological evaluation] determined that John Doe #117 was ‘cognitively limited,’ ‘schizophrenic’ and ‘not completely in control of his behavior.’”89

  • “Inmate [V.Y.A.] is a 40-year-old Black male with a history of chronic, Paranoid Schizophrenia with a positive response to anti-psychotic drug therapy. Inmate [V.Y.A.] initially reported auditory hallucinations, lack of sleep, and concerns about possible effects of blood pressure medication. His mental status deteriorated and regressed considerably while in the infirmary, including alternatively claiming to be Jesus and denying he was Jesus. His affect was often intense, agitated and paranoid threatening. Thought process was disorganized, grandiose, and delusional, with auditory hallucinations at times reported but at other times denied. Decompensation continued until Inmate [V.Y.A.] became compliant with medication regime…Assessment Diagnosis: Axis I: Schizophrenia, Paranoid, Chronic with acute exacerbation.”90

  • “[V.R.] is delusional and thought disordered; his speech is disorganized and tangential, with loose associations. He believes that he is ‘attached to an alien affiliation’ and that he has been forced to commit treason against the Untied States. He also claims that he is a woman, but ‘they haven’t found his vagina yet.’ He said that he shot his mother when he was three years old, but does not know if she died or not. He also reported that he believes that there is a radio in his nerves that is broadcasting. He often picks at his ear to see if the receiver is in there but can’t find it. He still believes it is there. He also gets messages through ‘federal codes’ in his cell.”91

  • “D.R. has been on psychiatric medication since the age of ten years old for hearing voices and what he calls ‘psychological illusions.’ He has had several previous psychiatric hospitalizations. He describes visual hallucinations of seeing ghosts, animals, people and things move. Auditory hallucinations are outside of his head, they are sometimes about Jesus, they take up to 500 different forms and talk to each other. They sometimes command him to kill himself although he has not made any previous suicide attempts. He is obviously severely mentally retarded and appeared to be blithely indifferent to his conditions.92

  • “Mr. BF is a forty year old black man who has been incarcerated since July 1994. [He] has a history of severe mental illness. During the period of incarceration preceding his arrival at Attica, he was psychiatrically hospitalized at CNYPC [Central New York Psychiatric Center] a total of seven times and was in and out of MHUs in the facilities where he was housed. On each occasion that he was transferred to CNYPC, he presented with symptoms of a highly agitated, confusional psychosis with some suicidal features. His clinical presentation has also included a great deal of agitated, bizarre and inappropriate behavior, including sexual preoccupations, grandiose ideation of being a rock star, and a fixation with princess Diana of Britain. At times he experienced visual and auditory hallucinations, and sometimes carried on loud conversations with the voices he heard. He was observed to be hearing voices and seeing strange people who were not there, and became preoccupied with spacecraft, aliens, voodoo, and the singer Mariah Carey. At times, he was observed to be overtly confused and disoriented, mumbling incoherently.… At times he was quite floridly ill, while at other times, he appeared to be reasonably coherent. His behavior was often grossly bizarre and inappropriate…[H]e was observed to have inserted a lighter, cigarettes, and pictures into his anus. On at least one occasion, he inflicted multiple lacerations on both sides of his face….He smeared feces on his cell wall — even using his excrement as a paint to write words on the walls. At times he was suicidal.93

  • “[A prisoner in Illinois] reports he hears voices of dead people: his brother…his own victim(s); voices usually happen at night. No visual, olfactory, gustatory or tactile hallucinations.… States that cutting his arms and legs helps him to relax. Sometimes it is intended to be lethal. Has no recollection of trying to eat his own flesh except as told to him by correctional staff…diagnostic formulation: Long-standing history of psychiatric treatment/psychiatric hospitalization(s) for depression and SSDI for physical and mental disorder. [While in prison] diagnoses of depression, dysthymic disorder, cyclothymia, adjustment disorder, adult attention deficit disorder, PTSD, impulse control disorders, atypical psychosis and personality disorders…Differential diagnosis includes: Major depressive disorder, recurrent, with psychotic features; Schizophrenia, undifferentiated type; Borderline personality disorder; Schizotypal personality disorder.94

  • Y.R. is an prisoner on Virginia’s death row. He was convicted of a triple-murder carried out when he was eighteen years old. Although he underwent a psychiatric evaluation conducted by a state expert, he was never given a mental health competency hearing, despite his lawyers believing him to be incompetent to stand trial.95 Y.R., who three psychiatric experts believe developed schizophrenia aged about sixteen, sometimes believes himself to be an incarnation of famous rap stars. At other times, he declares that he is God and that the Bible was written about him. He believes that when he is executed he will immediately return to earth, bringing with him all his dead relatives. When he acts out, bangs on the walls, or floods his cell, guards have, at least twice, placed him into four point restraints; because he is so ill, he cannot write to his attorney. She only finds out about these events when other prisoners on death row contact her and tell her what has been happening to her client.96

  • During our research, Human Rights Watch interviewed numerous other prisoners also identified bymental health staff, family members, or correctional staffas seriously mentally ill and whose illness was patent. For example, we interviewed a prisoner, V.P., at Corcoran State Prison, California who was incarcerated for murdering his wife because she had cheated on him. He told Human Rights Watch that he’d been playing a game called “no murder.” “I hear my wife. She talks about game playing. No Murder. She says she’s sorry she fooled around….. I think about game ‘no murder.’ I want to go home.” V.P. also said that his wife and her father had also killed him several times, but that he hadn’t died; and that the whole family had been playing this game for two thousand years.97

71 Human Rights Watch interview with D.O.T., California State Prison, Corcoran, Enhanced Outpatient Program, California, July 11, 2002.

72 Human Rights Watch interview with Dave Munson, head psychologist, McNeil Island Correctional Center, Washington, August 22, 2002.

73 Human Rights Watch telephone interview with Gary Field, administrator for counseling and treatment services, Oregon Department of Corrections, June 24, 2002.

74 Human Rights Watch interview with Gloria Henry, warden, Valley State Prison for Women, California, July 17, 2002.

75 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington D.C.: American Psychiatric Association, 1994).

76 This is the definition used by The President’s New Freedom Commission on Mental Health, “Achieving Promise: Transforming Mental Health Care in America,” p. 2 (July 23, 2003), available on line at:, accessed on August 26, 2003.

77 Ibid., xxi-xxii.

78 Hans Toch and Kenneth Adams, Acting Out: Maladaptive Behavior in Confinement (Washington D.C.: American Psychological Association, April 2002), p. 16

79 See Martin Drapkin, Management and Supervision of Jail Inmates With Mental Disorders (New Jersey, Civic Research Institute, 2003), ch. 4, which provides an excellent overview of the nature of and correctional implications of various mental diseases and disorders.

80 Human Rights Watch telephone interview with Dr. Jeffrey Metzner, clinical professor of psychiatry, University of Colorado Health Sciences Center, April 2, 2003. Dr. Metzner is a nationally recognized psychiatrist and correctional mental health expert who has provided evidence on prison mental health conditions in dozens of cases.

81 Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington D.C.: American Psychiatric Association, 1994), p. 629.

82 Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington D.C.: American Psychiatric Association, 1994).

83 Email communication from Dr. Terry Kupers to Human Rights Watch, May 29, 2003.

84 Sartx, Blazer, George & Winfield, “Estimating the Prevalence of Borderline Personality in the Community,” Journal of Personality Disorders, vol. 4, no. 3 (1990), pp. 257-272; Nehls, “Borderline Personality Disorder: Gender Stereotypes, Stigma, and Limited System of Care,” Issues in Mental health Nursing, vol. 19 (1998), pp. 97-112. Some mental health professionals believe the diagnosis of borderline personality disorder has become a demeaning “wastebasket” category into which difficult women are lumped. Email communication from Dr. Terry Kupers to Human Rights Watch, May 20, 2003.

85 Email communication from Dr. Terry Kupers to Human Rights Watch, May 20, 2003. See also, Judith Herman, M.D., Trauma and Recovery (New York: Basic Books, 1997).

86 Jones ‘El v. Berge, 164 F. Supp.2d 1096, 1108 (W.D. Wis., 2001).

87 Ruiz v. Johnson, 37 F. Supp. 2d 855, 909 (S.D. Tex., 1999).

88 Letter from Keith Curry, Ph.D. to attorney Donna Brorby, March 19, 2002, pp. 19-20; on file at Human Rights Watch. Brorby was the lead attorney in Ruiz v. Johnson, a lawsuit over Texas prison conditions, and Curry visited the prisons on behalf of the plaintiffs.

89 New Jersey Prison System Report of Dr. Dennis Koson, C.F. v. Terhune, Civil Action No. 96-1840 (D.N.J., September 8, 1998), on file at Human Rights Watch. The trial court approved the parties’ settlement of the case on July 30, 1999. D.M. v. Terhune, 67 F. Supp. 2d 401 (D.N.J., 1999).

90 Mental health evaluation of V.Y.A. by Illinois Department of Corrections, December 31, 1998; on file at Human Rights Watch.

91 Human Rights Watch, Cold Storage: Super-Maximum Security Confinement in Indiana (New York: Human Rights Watch, 1997), pp. 36-37. The prisoner was examined by psychiatrist Terry Kupers, who served as a consultant to Human Rights Watch.

92 Ibid., p.37. Psychiatrist Terry Kupers also examined this prisoner.

93 Dr. Stuart Grassian, Second Site Visit to the Attica SHU, Mental Health Care, Eng v. Goord, Civ 80-385S (W.D. New York, October 1999) (redacted copy). In his report, Dr. Grassian provides detailed descriptions of the conditions, behavior and medical history of eight seriously mentally ill inmates incarcerated in the secured housing unit at Attica. His report also documents in detail the failure of the mental health staff to provide proper treatment for these inmates and the deterioration of their conditions accompanying prolonged incarceration in segregation. Dr. Stuart Grassian, Second Site Visit to the Attica SHU, Mental Health Care, Eng v. Goord, Civ 80-385S (W.D. New York, October 1999) (redacted copy), p. 40.

94 Mental Status Evaluation of an inmate [name withheld] by Katherine Burns, M.D. dated April 3, 1999; on file at Human Rights Watch.

95 Human Rights Watch telephone interview with Jennifer Givens, attorney, Virginia Capital Representation Resource Center, October 2, 2002.

96 Ibid.

97 Human Rights Watch interview with V.P., Corcoran, California, July 11, 2002.

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October 2003