U.S. prison systems, at present, face two key forces for change which are often at odds: on the one hand, litigation to induce reform of mental health services, which prison officials are otherwise slow to undertake; and on the other hand, funding pressures and cutbacks that make implementation of reforms more difficult.
While it should not take the threat of a lawsuit to get correctional systems to improve their mental health services, in practice, litigation or the threat of it, is the prerequisite for systematic improvements in mental health services. The earlier lawsuits challenged the utter lack of mental health services in prisons. More recently, litigation has sought improvements in existing systems.
Class action lawsuits have led to improvements in prison mental health care in a number of states, including Alabama, Arizona, California, Florida, Indiana, Iowa, Louisiana, Michigan, New Mexico, New Jersey, New York, Ohio, Texas, Vermont, Washington, and Wisconsin. Lawsuits have led to consent decrees and court orders instituting reforms and the court appointment of masters and monitors to oversee compliance. Considering the needs of today’s mentally ill prisoners, the progress to date is far from enough. Viewed from the perspective of where prison mental health was two decades ago, the progress has been momentous.
Successful litigation does not necessarily translate quickly into actual improvement. Some directors of correctional agencies accepted on-paper compliance with court decrees as a substitute for real, durable reforms. Faced with court orders or consent decrees mandating improved mental health services, some correctional authorities resist putting reforms in place. The reluctance can stem from institutional inertia, bureaucratic obstacles, failure to understand the importance of adequate mental health services, or the lack of funding. For example:
One of the major impediments to adequate mental health services in prison is, quite simply, their cost — providing mental health care is expensive. For example, in Pennsylvania, the average prisoner costs $80 per day to incarcerate. Yet if an prisoner is mentally ill, the added costs of mental health services, medications, and additional correctional staff boost the average daily cost to $140.150 We have not been able to find figures for total national expenditures on prison mental health services.151 Many individual prison systems Human Rights Watch contacted indicated they were unable to calculate the portion of their medical budgets devoted to mental health services. Nevertheless, data on prison mental health services budgets from some states illustrate the sums involved, as well as reveal significant differences in the resources allocated to mental health. The differences reflect both decisions on quantity and quality of care to provide as well as regional differences in salaries for mental health professionals.
Table 2: Fiscal Year 2003-2004 Mental Health Care Budgets in State Departments of Corrections (DOC)152
** Includes amounts budgeted for contracted out mental health services.
The fiscal crisis currently gripping the fifty U.S. states has led to financial belt-tightening and budget cut-backs, including in prison budgets. Prison mental health services have not been spared. In Georgia, for example, the most recent mission statement published by the Office of Health Services boasts of having “reduced psychiatrists and psychologists staffing by 30% with significant budget savings.” The same report declares that, despite the risk of “moderate to significant medical and legal risk,” the department has decided, as a money-saving gesture, to abandon a plan to open a psychiatric unit at Johnson State Prison, even though this “will limit options for referrals of inmates in mental health crisis and inmates will have to be transported greater distances to access beds.” The department also decided to fill only 85 percent of vacant mental health counseling positions.162
In Florida, mental health director Roderick Hall told Human Rights Watch that it was impossible to estimate the amount of money spent by the correctional system on mental health services because “it’s not tabulated that way. The state budgets money for health care. The accounting structure doesn’t break down between mental health, physical health, and dental health.”163 However, despite the lack of specific numbers, the evidence suggests that Florida’s mental health services have also been impacted by budget tightening: a March 2001 Correctional Medical Authority committee meeting detailed Florida’s plans to cuts dollars from its correctional mental health expenditures through “cost saving efforts with psychotropic medications including reduction in the use of liquid psychotropics and limitation of formulary SSRIs [selective serotonin reuptake inhibitors] to two drugs.” The meeting also detailed how medications would be distributed only “twice [per day] in most places where possible due to limited resources.”164
In Michigan, a state that in recent years has made dramatic improvements to its system of mental health service provision within prisons, budget cuts took $5 million from the $72 million-hospital and prison mental health services in 2002 and fifty mental health service positions were slashed.165 According to the Director of Bureau of Forensic Mental Health Services in the Department of Community Health, Roger Smith, this has resulted in the number of treatment hours per patient in the intensive residential treatment programs being reduced from approximately twenty to twenty-three per week, down to sixteen.166 Tony Rome, clinical director of the Michigan Bureau of Forensic Mental Health Services, asserted that so far basic outpatient programming in Michigan’s prisons has not been cut. But, Rome acknowledged, the system is tightening up it criteria for outpatient eligibility.167
In Iowa, the corrections budget for fiscal year 2003 was cut 4.2 percent with proportionate cuts befalling the already-strapped mental health services.168 Massachusetts has also recently implemented significant cuts in its mental health programs for incarcerated offenders.169 And in South Carolina, the Department of Mental Health, responsible for administering mental health services to the state’s prisoners, recently lost $31 million in state funds, and $20 million from the federal government, and is facing another 5 percent cut to its budget.170
137 Dunn v. Voinovich, C1-93-0166 (S.D. Ohio, July 10, 1995). A description of the process by which the consent decree was reached is provided by Fred Cohen and Sharon Aungst, “Prison Mental Health Care: Dispute Resolution and Monitoring in Ohio,” Criminal Law Bulletin, July-August 1997, pp. 299-327. Cohen served as an expert in the pre-settlement Dunn process and subsequently served as the court-appointed monitor.
138 Coleman v. Wilson, 912 F. Supp. 1282 (E.D. Cal., 1995).
139 D.M. v. Terhune, 67 F. Supp. 2d 401 (D.N.J., 1999).
140 New Jersey Prison System Report of Dr. Dennis Koson, C.F. v. Terhune, Civil Action No. 96-1840 (D.N.J., September 8, 1998), p. 4, on file at Human Rights Watch. Human Rights Watch successfully sued the New Jersey Department of Corrections to secure public release of the Koson report. The settlement is reported at: C.F. et al. v. Terhune et al., 67 F. Supp. 2d 401 (D. N.J., 1999).
141 D.M. et al v. Jack Terhune et al. 67 F. Supp. 2d 401 (D. N.J., 1999.) The voluntary settlement committed the New Jersey Department of Corrections (DOC) to seek $16 million per year in additional mental health funding, and $2 million in construction funds to pay for new mental health facilities. The agreement is to remain in place until such time as the DOC has been found to be compliant with the terms of the settlement for one full year. Because it is a voluntary settlement, rather than one imposed by a federal court, it is not subject to the limiting time-constraints imposed by the Prison Litigation Reform Act. Human Rights Watch was not able to obtain permission from New Jersey Department of Corrections to visit any of its facilities or to interview officials concerning mental health services.
142 Ruiz v. Johnson, 37 F. Supp. 2d at 907.
144 Goff v. Harper, Findings of Fact and Conclusions of Law, No. 4-90-CV-50365 (S.D. Iowa, June 5, 1997) (unpublished).
145 Goff v. Harper, 59 F. Supp. 2d 910 (S.D. Iowa, 1999).
146 Goff v. Harper, 235 F. 3d 410 (8th Cir., 2000).
147 Fred Cohen, “Iowa Struggles to Provide Constitutionally Acceptable Mental Health Care: Promises Made?” Correctional Mental Health Report, July/August 2003, p. 19.
148 Palmigiano v. Garrahy, 443 F. Supp. 956 (D.R.I., 1977), remanded on issue of deadlines, 599 F. 2d 17 (1st Cir. 1979); defendants found in contempt of court, 737 F. Supp. 1257 (D.R. I. 1990). The court ordered defendants to hire an adequate number of mental health professionals to diagnose, treat, and care for those prisoners who have mental health problems. It also ordered defendants to bring the health care delivery system into compliance within six months with the minimum standards of the American Public Health Association, the United States Public Health Service, and the Department of Health, State of Rhode Island.
149 Palmigiano v. Garrahy, 639 F. Supp. 244 (D.R.I., 1986). The court noted that:
Palmigiano, 639 F. Supp. at 246.
150 U.S. Senate Judiciary Committee, Statement of Dr. Reginald Wilkinson, director, Ohio Department of Rehabilitation and Correction, “Mentally Ill Offender Treatment and Crime Reduction Act of 2003,” S. 1194, 108th Congress, July 30, 2003.
151 The average national daily cost per inmate for health care – medical and mental health care – in 2001 was $7.39. Camille G. Camp and Camp, George M., Corrections Yearbook 2001: Adult Systems (Connecticut: Criminal Justice Institute, 2002), p. 106. A breakdown for mental health services alone was not provided.
152 Caution must be used in comparing budgets because of differences in how state agencies calculate budgets.
153 BJS, Prisoners in 2002, table 3.
154 Human Rights Watch telephone interview with Terry Thornton, spokesperson, California Department of Corrections, June 16, 2003; California Legislative Analysts Office, Analysis of the 2000-2001 Budget Bill, accessed online at: http://www.lao.ca.gov/analysis%5F2000/crim%5Fjustice/cj%5F2%5Fcc%5Fmentally%5Fill%5Fanl00.htm. According to the analysis: “[t]he number of CDC inmates receiving such treatment has grown primarily because of court rulings requiring that the state to do a better job of identifying mentally ill offenders and a better job of providing services to those it has identified as needing treatment.”
155 Figures provided in electronic correspondence to Human Rights Watch from Peggy Chapman, public relations and information specialist, Georgia Department of Corrections, June 12, 2003 and from Georgia Health Services, Overview, Fiscal Year 2002. Although the amount budgeted rose from $24 million in 2001, the number of mentally ill prisoners increased by 500, resulting in a net decrease in the amount per prisoner. A portion of the state’s funding for mental health services comes from kickbacks from prisoners collect phone calls provided by the telephone service provider to the Department of Corrections. Human Rights Watch telephone interview, Bill Kissell, director of health services, Georgia Department of Corrections, February 5, 2003.
156 Human Rights Watch telephone interview with Tori Ellison, budget analyst, Michigan Department of Corrections, June 12, 2003.
157 Human Rights Watch telephone interview with John Calabrese, assistant finance director, Minnesota Department of Corrections, June 12, 2003.
158 Human Rights Watch telephone interview with Barbara Kutrzyba, manager II, Fiscal Resources, New Jersey Department of Corrections, June 12, 2003.
159 Electronic correspondence to Human Rights Watch from Richard Frechette, associate director/CFO, Rhode Island Department of Corrections, June 13, 2003.
160 Electronic correspondence to Human Rights Watch from Celeste Byrne, budget director, Texas Department of Criminal Justice, July 21, 2003; Human Rights Watch telephone interview with Celeste Byrne, August 18, 2003.
161 Electronic correspondence to Human Rights Watch from Trenton Howard, budget manager, Washington Department of Corrections, June 13, 2003.
162 In 2002, Georgia spent $9.60 per day per inmate on health services (mental and physical); Alabama spent $4.13. Data provided in Georgia Department of Corrections, Office of Health Services, Georgia Department of Corrections, Health Services Overview for 2002, available online at: http://www.dcor.state.ga.us/pdf/hsovrFY03.pdf, accessed on July 1, 2003. The numbers are from p. 9; the quote is from p. 40.
163 Human Rights Watch telephone interview with Roderick Hall, mental health director, Florida Department of Correction, April 14, 2003.
164 Minutes from Correctional Medical Authority Mental Health Committee Meeting, March 23, 2001.
165 Human Rights Watch telephone interview with Roger Smith and Tony Rome, director and clinical director, Michigan Bureau of Forensic Mental Health Services, June 19, 2002.
166 Human Rights Watch telephone interview with Tony Rome, clinical director, Michigan Bureau of Forensic Mental Health Services, June 19, 2002. In a subsequent telephone interview, February 10, 2003, Tony Rome told Human Rights Watch that the number of treatment hours per week was being cut to twelve hours.
167 Human Rights Watch telephone interview with Tony Rome, April 21, 2003.
168 Human Rights Watch telephone interview with Harbans Deol, medical director, Iowa Department of Corrections, April 2, 2003.
169 Human Rights Watch telephone interview with Dr. Thomas Conklin, medical director, Hampden County Jail, October 9, 2002. Hampden County Jail deals with low-level state prisoners as well as county inmates, ibid.
170 Editorial, “Deplorable Conditions,” Greenville News, December 8, 2002.