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The goal of mental health services in prison, as in the community, should be to facilitate recovery and to build the resilience and coping skills needed to improve independence and quality of life. Unfortunately, prison mental health services are focused primarily on managing mental health crises and managing symptoms. Strapped for funding and operating within a public climate that emphasizes the punitive purpose of prisons, correctional agencies have not taken advantage of the opportunity they have to make significant long-term differences in the lives of their mentally ill prisoners. Many prisons, indeed, do not even provide adequate basic mental health treatment.

Over the past decade, organizations such as the National Commission on Correctional Health Care (NCCHC), individual correctional mental health experts, court decisions, and settlement agreements have produced detailed guidelines on the necessary components of mental health care inside prisons. Prisons must have procedures for screening and identifying mentally ill prisoners; a range of mental health treatment services, including appropriate medication and other therapeutic interventions; a sufficient number of mental health professionals to provide adequate services to all prisoners suffering from serious mental disorders; adequate and confidential clinical records; protocols for identifying and treating suicidal prisoners; procedures to ensure timely access by prisoners to necessary mental health services; and different levels of care, from emergency psychiatric services and acute inpatient wards, to intermediate levels of care, to “outpatient” services.

Our research suggests, however, that no prison system provides all of these components. While many have carefully developed protocols and policies, implementation often lags far behind and appropriate services are not available for all the prisoners who need them. As the court reviewing the constitutionality of psychiatric care in Texas prisons noted, in a conclusion that is applicable to many prison systems, the Texas prison system’s “carefully developed policies and procedures notwithstanding, it is determined that the plaintiffs’ experts’ assessment of poor implementation of those policies and procedures is both substantially credible and a matter of extreme concern. Simply stated, large numbers of inmates throughout the TDCJ [Texas Department of Criminal Justice] system are not receiving adequate health care.”296

Other than litigation, mechanisms for ensuring adequate mental health services are scant. According to Judy Stanley, director of accreditation for the NCCHC, only 231 of the nation’s approximately 1,400 prisons have received NCCHC accreditation, meaning that they adhere to NCCHC guidelines and submit themselves to monitoring by the organization. The NCCHC does not monitor the actual quality of the care provided to prisoners. Most state correctional systems do not have procedures for independent review of the quality of the mental health services they provide. Our research also suggests that even internal quality control mechanisms are typically ineffective.

In this chapter, we look at a few specific mental health service problems that are particularly salient across the country and which suggest the magnitude of the problem confronting corrections.


Effective mental health services are staff intensive. A range of mental health professionals are needed — including psychiatrists, psychologists, counselors, nurses, recreational/occupational therapists — if individuals with serious mental illness are to receive the individualized mental health interventions required to address their psychiatric needs.All of the correctional officials and mental health experts Human Rights Watch interviewed while researching this report stated that the single most important requirement for good mental health services is adequate staffing levels. At the same time, almost every one of them also asserted that understaffing is the most critical problem facing prison mental health systems.

As of January 2001, according to the 2001 Correctional Yearbook, forty-nine correctional agencies reported having a total of 17,640 mental health and counseling staff.297 Of these, 18.4 percent are psychiatrists or psychologists. Counselors, who typically need no mental health degree or training and “others” accounted for 58.6 percent of the total.

There are no hard and fast rules for how many mental health professionals, and of what kind, are needed for each prison — or within a prison system. “The fundamental policy goal should be to provide the same level of mental health services to each patient in the criminal justice process that should be available in the community,” stated a 2000 report by the American Psychiatric Association.298 In this report, the authors wrote that in prisons the caseload of each full-time psychiatrist or equivalent should be no more than 150 patients on psychotropic medication.299 Experts recently hired by the state of Washington to generate long-term mental health proposals for the prison system, advocated ratios of one psychiatrist for every two hundred offenders with outpatient mental health needs; one supervising psychologist per institution; one mental health professional for every seventy-five seriously mentally ill prisoners, and one mental health nurse per one hundred patients.300 Caseloads in this range, the experts believed, would allow mental health specialists adequate time with each patient to properly diagnose them and develop individualized treatment plans. Experts we consulted indicated that few correctional institutions nationwide meet these staffing levels.

Iowa, for example, has a prison population of over eight thousand, of whom, 1,800 to two thousand are mentally ill. 301 The entire Department of Corrections has only thirty psychologists, most of whom, according to medical director Harbans Deol, have only a bachelor’s degree. In addition, there are three psychiatrists for the entire prison population. To meet appropriate staffing ratios, Deol said the prison system would have to hire eight more psychiatrists. But, he continued, “we don’t have the money for it. And it’s very hard to attract psychiatrists to the Department of Corrections.”

The mental health director for Arkansas’s Department of Corrections, which has almost fourteen thousand prisoners, informed Human Rights Watch that the department employed four full-time psychiatrists.302 Unlike most states, which have found that somewhere in the region of 8 to 15 percent of their prisoner population suffers from a serious mental illness, Arkansas estimates that only 4.7 percent of its prisoners are on psychotropic medications and on the mental health caseload. This would suggest an acceptable psychiatrist/patient ratio of one to 164. However, it is likely that the startlingly low number of mentally ill on the mental health caseload is more a product of under-diagnosis than it is a genuine reflection of the mental health status of Arkansas’s prisoners. Assuming that Arkansas prisoners in fact are as statistically prone to mental illness as the rest of the country’s prison population, it is likely that the four psychiatrists are actually working in a system housing closer to 1,500 mentally ill prisoners.

The Department of Justice, which conducted an investigation in 1998 of conditions at Wyoming State Penitentiary pursuant to the Civil Rights of Institutionalized Persons Act, found that the prison had a psychiatrist on the premises only two days per month. “The psychiatrist sees approximately 25 inmates per month, but cannot keep up with the number of new mental health referrals,” they wrote. In one three-month period, ninety-five new cases were referred to the mental health team, but:

WSP [Wyoming State Penitentiary] administered only six psychiatric diagnostic evaluations during this time period. Due to inadequate staffing, if seen at all, most inmates in need of crisis psychiatric intervention were seen by an infirmary physician rather than by a trained mental health care provider.303

A New York State Office of Mental Health Taskforce report in 1997 on prison mental health services found that:

Outpatient staffing has remained relatively constant at approximately 215 in the last four years, while the demands, in terms of evaluations, admissions, treatment, commitments, discharges, and linkages has risen. Similarly, satellite outpatient mental health resources have not kept pace with the changes in and volume of the correctional population…. New York has lower per capita inpatient beds than all other states of comparable or smaller DOC population with the exception of New Jersey…. New York has clearly not kept pace, per capita, with the rise in this state’s prison population and has not had resources increased, in some cases, in many years.304

Inadequate mental health staffing occurs because prison systems are funded for too few positions and the funding has not increased to keep pace with the burgeoning prison population. In addition, prison administrators have a difficult time filling mental health positions because the pay offered prison staff is often too low, the work environment is often unpleasant, prisons are frequently situated in out-of-the-way places, and working in corrections has historically been seen as “low status.” In Florida, the Correctional Medical Authority (CMA), the oversight body responsible for ensuring the delivery of medical and mental health care in Florida prisons, discussed in 2001 the proposition that mental health staffing ratios should “reflect available resources.” According to the minutes of the CMA meeting:

Discussion ensued about the appropriateness of that approach with several members expressing the belief that the plan should contain two sets of ratios: one based on what is clinically appropriate and one based on available resources. 305

One doctor present pointed out “that with caseloads [for psychologists] of 60-to-80, psychotherapy will not occur to the extent necessary.”306

The director of mental health for the Maine Department of Corrections complained that it was hard to keep psychiatrists working for the department, and told Human Rights Watch that psychologists were paid up to $20,000 a year less in prison than in community settings.307 In Virginia, a starting salary for a psychologist working within the correctional system is only $31,935.308 This is lower than the starting salary for psychologists offered by the Northern Virginia Training Center residential facility six years ago. In 1997, starting salaries for psychologists there ranged from $34,943 to $54,500.309 It is also significantly lower than the starting salary offered school psychologists — in August 2003, York County advertised a position for a school psychologist paying $35,186.310

Understaffing also reflects high rates of turnover in mental health staff — itself caused by the pay and quality of work considerations noted above and the consequent difficulty of recruiting replacements. The turnover of mental health staff adversely affects mental health services: new staff are not as familiar with prisoners mental health histories and behavior, and staff changes disrupts the development of the prisoner confidence and trust which is crucial to effective therapeutic relationships.

Randall Berg, an attorney representing seriously mentally ill prisoners in Florida’s highest security prisons, told Human Rights Watch that he believed as many as one quarter of mental health positions in these prisons were vacant. “There’s a significant staff turnover,” he stated. “So there’s no continuity of care.”311 At the Washington Correctional Center for Women (WCCW), “since 1996, there have been six different mental health supervisors, and a slew of other key mental health staff have quit — many in frustrated desperation.”312

Following a court ruling that California’s deficient mental health services violated the Eight Amendment,313 the state’s budget for mental health services has grown considerably. Indeed, just between 2001 and 2003, the budget has increased 20 percent, even though the prison population has been relatively stable.314 The state’s per capita expenditures for mental health services are reputed to be among the largest in the country.315. Yet, even in California, mental health services at many prisons are understaffed. At the California Medical Facility, California, prison psychiatrist Radu Mischiu told Human Rights Watch that “turnover is huge,” and asserted that the average stay for mental health staff in the prison was a mere six months.316 In December 1998, the Office of the Special Master appointed under Coleman reported that while the prison was funded for 8.5 full time psychiatrists, because of staffing turnover the prison only had 5.5 of the positions filled.317 In April 2002, the Special Master reported that positions for two psychiatrists, five psychologists, a half-time psych tech, and an office assistant were vacant at Pelican Bay. At Pleasant Valley State Prison, the chief psychiatrist’s position had been vacant almost a year. At Wasco State Prison, six psychologist positions were unfilled. And at Avenal, the one full-time psychiatrist was found to only be working thirty-six hours per month.318 In October 2000, the Special Master appointed by the Court in the wake of the Madrid case wrote about the Psychiatric Services Unit (PSU) at Pelican Bay State that “the PSU has suffered chronic staffing shortages, including psychiatrist shortages and a long-term problem with inadequate numbers of psychiatric technicians. The direct result of this shortage is the PSU’s failure to provide adequate out of cell structured therapy.”319

Low staffing levels combined with the high rates of turnover have contributed to the mental health crisis behind bars in many states. For example, in Maine, external auditors monitoring mental and medical health services noted that between 2000 and 2001 all three of the state’s prisons had experienced:

notable slippage in the quality of care delivered…. Factors contributing: turnover of key health administrators, vacancies in PA [Physicians Assistants] and Psychiatrist positions, time on move to new facility takes away from day to day administration, emphasis on cost containment by medical director.320

While Joe Fitzpatrick, clinical director for the Maine Department of Corrections, told Human Rights Watch that the vacant positions had been filled since the audit was conducted, he also reported that, because of budget constraints, a bill to improve the mental health services offered to incarcerated individuals was recently trimmed of all additional financial obligations. Currently none of the prisons, including the one housing a small, specialized mental health unit, has a full-time psychiatrist. Instead, two prisons have a psychiatrist assigned two days a week and one has no psychiatrist but does have access to the nearby state mental hospital.321

The qualifications, training, and competence of prison mental health staff should be equal to community standards.322 But the hiring of under-qualified, and thus lower-paid, staff is one way in which prisons lower their mental health costs. Throughout our research, questions arose concerning the qualifications of the mental health staff that work in prisons. A 1988 nationwide survey found that 40 percent of mental health staff in prisons had less than a Master’s degree.323 Human Rights Watch was unable to find updated data on this. Nevertheless, there have continued to be periodic reports of states utilizing under-qualified counselors and psychologists, or staff whose licenses to practice in the free world have been suspended.324 Dr. Jeffrey Metzner told Human Rights Watch that in many of the prison systems he has visited, unlicensed psychologists are inadequately supervised by licensed practitioners. “They frequently have supervision on paper only,” Metzner asserted. “I’ve seen counselors with a B.A. in home economics.”325 Oftentimes, Metzner also noted, for-profit companies brought in to deliver correctional mental health services employ licensed clinical directors and fill the rest of the psychologists’ and case workers’ positions with unlicensed practitioners whom they can pay less. “Many of the companies do that to one extent or another.” In Rhode Island, mental health director Frederick Friedman told Human Rights Watch that four of the system’s five psychologists are unlicensed.326 In Iowa, only two of the eighteen psychologists have PhDs, the rest having either Bachelor’s or Master’s degrees.327 In 1997, the mental health staff at Indiana’s Maximum Control Facility’s (MCF) consisted of a behavioral clinician with a Master’s degree in counseling psychology, who also served as the superintendent’s administrative assistant.328

In some prisons Human Rights Watch visited, senior mental health staff, including some psychiatrists, appeared to have serious problems conversing in English. Human Rights Watch doubted some of these employees could easily communicate with many of their prisoner-patients. In other settings, we found prisons reliant on staff who likely did not have the licenses that would allow them to practice in the private marketplace. In Graterford Prison, Pennsylvania, for example, large-scale investments havebeen made in mental health care over the last few years, and Human Rights Watch found the staff to be uniformly dedicated and caring individuals. Nevertheless, of the fourteen psychologists employed at the prison, not a single one had a PhD, and only three of the fourteen were licensed psychologists. Louis Mariani, chief psychologist at Graterford, told Human Rights Watch that the advantage of hiring unlicensed psychologists was that they were cheaper than their licensed peers. “I don’t know if the Commonwealth of Pennsylvania would let us hire licensed psychologists — because they’d have to pay them [more].”329 The counselors there “can have a Bachelor’s degree in just about anything,” Mariani asserted, and don’t need any formal mental health training. In Mississippi, according to the University of Mississippi Medical Center’s Linda Powell, none of the too-few psychologists employed within the system have PhDs.330 In South Carolina, investigators from the Legislative Audit Council published a report in March 2000 severely criticizing the quality of medical and mental health care in the state’s prisons, especially in those prisons that had contracted out their services to a private company named Correctional Medical Services (CMS), which is the largest private corrections health care provider in the country. The investigators found that “inmate counseling staff at both CMS and SCDC [South Carolina Department of Corrections] sites did not meet the minimum qualifications for their positions.”331

The downside of such a practice is obvious. As Judy Stanley, director of accreditation for the National Commission on Correctional Health Care, points out, it means under-trained, and under-qualified personnel end up making clinical decisions about appropriate treatment strategies and crisis interventions for seriously mentally ill prisoners.332 For example, plaintiffs’ expert Dr. Roberta Stellman, testified in the Texas prison litigation that nurse practitioners made serious diagnosis and prescription decisions.333

Mental health intervention decisions are also made — or not made — by untrained personnel because mental health staff typically do not work weekends or evenings in prisons. Correctional and security staff are left to respond to the needs of mentally ill prisoners. Indeed, mental health crises apparently happen more frequently on the weekends and evenings.

Poor Screening and Tracking of Mentally Ill Prisoners

The identification of prisoners with mental illness is the necessary predicate for mental health treatment. U.S. courts have repeatedly noted that the U.S. Constitution requires adequate screening and monitoring for mental illness.334 Nevertheless, in many prison systems screening and tracking of mentally ill prisoners is problematic. Prisoners with mental illness are not identified upon entry into prison and are left untreated. If they are identified after screening and placed on mental health caseloads, prison data management systems often are inadequate to track services provided, or to ensure that the prisoners’ records follow them when they are transferred to different prisons. In addition, prisoners who develop mental health problems after admission are often not identified and placed on the mental health caseload in a timely manner.

Initial screening occurs when a prisoner is admitted for the first time to a facility — either in the transfer to prison from jail or, in some systems, when a prisoner is transferred between institutions. The screening typically consists of a questionnaire which prisoners answer. If a good questionnaire is used, the administrative staff need not have much or any mental health training. If the screening questionnaire is adequate and properly administered, such personnel will probably have a fairly good rate of referring intake prisoners for more in-depth evaluations.

According to the Consensus Project, effective screening should enable a determination of prisoners in need of immediate mental health attention within twenty-four hours or within a brief reasonable time frame of three to seven days. If the screening suggests the prisoner is in need of mental health treatment (e.g., if the prisoner indicates that he or she has been receiving medication for a mental illness, or has been previously hospitalized for mental illness), the prisoner should receive a more comprehensive examination that includes an inquiry into mental health histories, an interview with the prisoner by qualified mental health staff, and review of health care records and other pertinent information. Unfortunately, staff conducting the initial screening as well as more comprehensive examinations usually do not possess the results of prior psychiatric assessments, even assessments made during the prisoner’s pre-trial incarceration or psychiatric diagnoses undertaken as part of trial competency or insanity defense proceedings. Such prior psychiatric workups may, indeed, never make it to the prison. 335

The Michigan Bureau of Forensic Mental Health Services has created a comprehensive prison screening infrastructure. Nevertheless, officials believe that they miss, at intake, between six and eight seriously mentally ill prisoners per month, according to Director Roger Smith. These individuals are identified during subsequent follow-up screening processes. Using computerized databases, the system has the capacity to identify the individual prison clinicians who are repeatedly failing to identify these mentally ill prisoners, and can put them under a more intensive supervision regimen.336 Connecticut is another state that has invested in the creation of a sophisticated mental health care database.

Most states, however, do not have such databases in place, and in these states mentally ill prisoners not identified during intake-screening are at risk of going without needed treatment throughout their stay behind bars. “Those systems that are suffering,” Smith believes, “are those that don’t have the ability to monitor on a regular basis what is going on in their system. If you can’t do that, things can get out of control pretty quickly.”337

Some states, such as Alabama, have barely begun computerizing any aspect of their correctional mental health systems.338 In Wisconsin, a 2001 legislative audit found that the Department of Corrections had no way of determining the total number of seriously mentally ill prisoners in its system.339

In Wyoming, investigators from the Civil Rights Division of the U.S. Attorney General’s office concluded that:

WSP [Wyoming State Penitentiary] provides virtually no diagnostic assessments utilizing past treatment records and diagnoses, multi-disciplinary treatment planning, or aftercare planning…. WSP’s erratic mental health care documentation exacerbates these problems. The prison often fails to document services rendered, mental health records do not contain physicians’ orders, and the records have large gaps during periods of critical care.340

In California, Doug Peterson, chief deputy clinical services and head of health care at California State Prison, Sacramento, readily admitted that his prison’s database is “horrible as a management tool, which affects inmate care. It’s harder to monitor whether they’re getting what they’re supposed to be getting.”341

Protocols developed by the American Correctional Association, the National Commission on Correctional Health Care, and through litigation recommend that prisoners be monitored, at regular intervals, for emerging mental illness throughout their stays in prison. Prisoners whose initial intake screening does not reveal a serious mental illness do not need to be seen by mental health staff as regularly as do those so identified. But, they do still need some access to, and regular monitoring by, mental health staff. Because many people first develop serious mental illnesses while in their late teens and twenties — the age group that makes up the bulk of incoming prisoners — the fact that an initial intake-screening process finds an individual to be free of mental illness is no guarantee that they will remain healthy throughout their sentence. “It is almost impossible,” said Toch, “to predict which of the vulnerable inmates you put into these settings are going to fall apart in them.”342 This observation is made more urgent by the fact that prisons are high-stress environments, particularly likely to trigger mental health problems amongst individuals vulnerable to such sicknesses. And yet, as Fred Cohen pointed out, because they are already overworked, “prison mental health staff aren’t looking for business, for more customers.”343 In many prisons, there is no routine monitoring of mental health of prisoners who are not on mental health caseload, even when the prisoners are in notoriously stressful settings such as segregation that can prompt mental health crises. (See chapter XII below.) Prisoners who are not on mental health caseloads only obtain mental health services either through self-referrals, the referrals of other prisoners, or the referrals made by security staff.

The following example from Texas reveals how extremely impaired prisoners can remain outside the prison mental health system. Forensic psychologist Keith Curry, reporting on a site visit to Smith prison on behalf of plaintiffs in the Ruiz litigation, wrote of:

a 39 year old man admitted to Smith [prison] from Coffield on September 19, 2001 where he had been treated with a dose of antipsychotic medication for the diagnosis of Psychotic Disorder NOS. Since the patient’s medication was discontinued shortly before transfer, the nurse at Smith did not pick up on the psychiatric history upon chair review. This occurred despite descriptions of extensive prior treatment and an impatient admission for bizarre behavior and psychotic decompensation as recently as January 22, 2001. As a result, no referral was made to mental health. The inmate was observed on rounds by the psychiatric nurse on October 1 and 11, 2001 after custody staff commented upon the inmate’s bizarre behavior. The nurse noted that the inmate was, “delusional, disorganized, agitated, labile, with rapid speech, flight of ideas, and loosening of associations.” Despite this, she noted that he was in, “no apparent distress.” She nonetheless suggested that he see the physician’s assistant for a medication evaluation. However, the inmate declined this offer and no further mental health notions were made in his medical record. [On the day of Curry’s visit in mid-March, 2002] the inmate was highly agitated with prominent paranoid delusions. He was grossly disoriented with rapid speech, loosening of associations, clang associations, and apparent responses to internal stimuli. This inmate would stand out as severely impaired on any psychiatric inpatient unit, but was receiving no mental health services while being locked in a windowless box 24 hours a day for six months.344

Ruling on mental health conditions in Iowa State Penitentiary in 1997, a federal district court found a lack of repeated follow-up evaluations for prisoners. Testimony at trial revealed that “inmates who develop problems after entering the system or inmates whose problems do not manifest themselves until they have been in the system for a while are often left undiagnosed. These are the inmates most likely to end up in the lockup cellhouse….”345

Lack of Timely Access to Mental Health Staff

As the American Psychiatric Association (APA) points out, “[t]imely and effective access to mental health treatment is the hallmark of adequate mental health care.”346 It has concluded, however, that in prison such access is impeded by delays in transmitting prisoners’ oral or written request for care; permitting unreasonable delays before patients are seen by mental health staff or outside consultants; and the imposition of fees that prevent or deter prisoners from seeking care.347 Indeed, one of the most frequent complaints voiced by mentally ill prisoners is that they have to wait days, weeks, and even months to see mental health staff after they request a meeting or to have their medications altered. Based on testimony and information Human Rights Watch collected during research for this report, we believe that this lack of access is a product both of understaffing and of a prison culture that tends to view prisoners as inherently manipulative and thus not truly in need of mental health interventions.

  • In Georgia’s Phillips State Prison, a psychiatrist’s review of prisoner treatment documents indicated that, “[e]ssentially all inmates are seen by the psychiatrist at one month intervals regardless of their clinical condition. There were multiple instances in which records documented a worsening of symptoms (psychosis, thought disorganization, behavioral manifestations of mental illness, depression, weight loss, etc.) with no plan to schedule the inmate for a psychiatric appointment before the next regularly scheduled appointment or to provide any other type of intervention. This practice promotes needless suffering and worsening of psychiatric illness.”348

  • In 1994, Gregory Stampley, a prisoner with a long history of schizophrenia, died in Minnesota’s Stillwater prison. According to a newspaper report based on evidence presented during a subsequent lawsuit brought by his family, Stampley spent the last days of his life:

in a small concrete cell soiled by his own excrement, babbling incoherently, drinking water scooped from a toilet and refusing to accept prescribed medication from his guards. Twice, guards tried unsuccessfully to arrange for a prison psychologist to go to Stillwater to examine Stampley.349

A year later, the state prison ombudsman wrote that the Department of Corrections had often failed to provide treatment for mentally ill inmates in a timely manner.350 She also concluded that the guards had unnecessarily kept Stampley in a restraint board to control his behavior. In the lawsuit, Stampley’s mother claimed the prison system failed to give her son adequate care and accused the staff of neglect and abuse. The state denied the charges but nonetheless agreed to pay Stampley’s family $168,500 and to make psychologists available twenty-four hours a day, either in person, or via telephone, to consult with guards.351

  • A 1998 investigation by the U.S. Department of Justice into conditions at the Wyoming State Penitentiary found that the mental health staffing was so inadequate that out of ninety-five people referred to mental health services in a three-month period, only six were actually given psychiatric evaluations. “Due to inadequate staffing,” a report to Governor James Geringer noted, “if seen at all, most inmates in need of crisis psychiatric intervention were seen by an infirmary physician rather than by a trained mental health care provider.” In the administrative segregation unit of the prison:

Inmates who had been receiving mental health services outside of administrative segregation experienced discontinuity in care once assigned to the unit. For example, we discovered numerous instances of inappropriate cessation of long-standing mental health medications. Likewise, inmates widely complained of and our chart reviews confirmed a general lack of responsiveness to mental health services requests from administrative segregation unit inmates.352

In their report, the investigators referred to one case in which “an inmate with a history of state hospitalization requested mental health assistance. Mental health personnel, however, did not see this individual for over a month, waiting until he attempted to commit suicide by slashing his wrists.”353

  • Experts investigating mental health services in Alabama prisons found that:

Outpatient services for inmates identified as experiencing serious mental illness are provided by CMS [Correctional Medical Services] mental health staff who may be present in a particular facility only one or two days per week. The ADOC [Alabama Department of Corrections] psychologists are not responsible for the monitoring and treatment of inmates with serious mental illness. Inmates who experience emergencies on days when a CMS mental health staff member is not present are routinely placed on watch in isolation until the CMS staff member’s next scheduled day. Isolation alone, particularly under the conditions previously described, is inadequate treatment for mental health emergencies and exacerbates the inmate’s distress and suffering.

On days when a CMS mental health staff member is on-site, the number of outpatient inmates requiring just routine monitoring is so great that it results in these inmates receiving little more than a brisk, “How are you doing?” Any hope of facilitating an inmate’s adjustment to correctional living and enhancing treatment compliance through education is not achieved.354

  • Because of the above-mentioned poor mental health coverage in Mississippi’s prisons, seriously mentally ill prisoners in the three state prisons have only minimal access to mental health staff. According to Linda Powell, at Mississippi State Penitentiary at Parchman, prisoners only see their psychiatrist every ninety days and only have contact with their psych assistants — the staff who are supposed to be on the lookout for mental health problems — once a month.355

Diagnoses of Malingering

Many prisoners with serious mental illness go untreated or are under treated because staff dismiss their symptoms as faking or manipulation. According to Fred Cohen, a high incidence of diagnosis of “malingering” mental records is a “sign of a system in disrepair.”356

There are no obvious criteria for determining whether or when an prisoner’s behavior reflects mental illness or not. “Disruptive or violent conduct may be a manifestation of illness or just orneriness. Quiet, seemingly introspective behavior may be just that or it may be evidence of decompensation.”357 But the ability to make just such determinations is, after all, “part of the mental health clinician’s art, inside or outside prison walls.”358 Security staff, who lack mental health training, are often quick to assume that prisoners are acting volitionally or manipulatively when they act out.

Unfortunately, some correctional mental health staff are also too quick to see malingering or manipulation and to overlook mental illness. Prisoners can, of course be manipulative, feigning mental illness for numerous reasons — to gain a transfer, change housing assignments, seek attention, or to improve their legal situation. But manipulation is not inconsistent with mental illness. Behavior such as self-mutilation can be manipulative. But it can also — and simultaneously — be a symptom of a major psychiatric disorder or a self-reinforcing behavior that requires a psychiatric response. In facilities in which the staff lack either the time or the inclination to pay close attention to prisoners, the only option left to a prisoner seeking mental health attention is to manipulate in some way — for instance by creating a disturbance or exaggerating his pain. The less attentive or present the staff, on average, the more manipulative prisoners have to be to get attention, and this is as true for prisoners who are suffering from serious medical or psychiatric ailments as it is for those who are not ill but merely want attention. In other words, seriously mentally ill prisoners are also frequently “manipulative” to get the care they need.

Absent careful evaluation through diagnostic work-ups, it is impossible to determine whether a self-mutilating individual has genuine psychiatric problems — for instance, he might be commanded by hallucinatory voices to cut himself — which, in turn, he may be exaggerating in order to receive needed help. Unfortunately, in some facilities, the “prevailing apprehension among custody and clinical staff [is] of being manipulated into delivering psychiatric services…. The suspicion of malingering and its accompanying withholding of services are particularly acute in the management of self-mutilation and explosive disorders.”359 Diagnoses of malingering or manipulation too often reflect issues of available resources, security concerns, and belief in prisoner pursuit of secondary gains rather than the result of careful objective evaluations.

  • In Texas, as part of the Ruiz litigation, plaintiffs’ experts presented examples of misdiagnosis to suggest the ongoing poor quality of psychiatric care in Texas prisons. Dr. Jeffrey Metzner indicated that system-wide deficiencies included “not recognizing or minimizing symptoms indicative of major mental illnesses by either over-diagnosing malingering or ‘no Axis I diagnosis.’”360 Dr. Metzner described the case of a prisoner who was initially diagnosed as schizophrenic, and who had a history of smearing himself with feces, complaining of auditory and visual hallucinations, and claiming to be the Messiah. However, a Dr. Taylor later determined the prisoner was malingering and expressed interest in whether in the future he would consume his feces or just smear them. Another prisoner:

entered the system with a history of suicide attempts, self-mutilations, hallucinations, and hospitalizations. His medications were discontinued and he was diagnosed as having no Axis I illness. After a brief visit to Skyview [an in-patient psychiatric facility] he was discharged with Dr. Tchokoev recommending no medication and heavy work in the field. The same day he returned to Beto [a prison unit], he cut himself and then attempted to hang himself. He is now in a vegetative state.361

  • In yet another example, a prisoner went to Skyview after a long history of psychiatric treatment for a number of Axis I and Axis II diagnoses, both in the free world and the Texas Department of Criminal Justice. Once there, Dr. Taylor discontinued his medication and asserted, “[t]his patient has a history of acting out at this facility when he is ‘found out’ and is aware of the fact that he will be returned to his unit of assignment.” By the end of the month, he had returned to Crisis Management and received two more, different Axis I diagnoses.362

  • In New York,psychiatrist Stuart Grassian made a site visit to Attica one year after a successful lawsuit ended concerning mental health services in that prison. Dr. Grassian found that appropriate mental health treatment for prisoners remained frustrated by “the inappropriate and long-standing preoccupation of Attica OMH [mental health] staff with rooting out malingering…. The records that I have reviewed demonstrate that there is a persistent over-reliance on ‘malingering’ and ‘manipulating’ — sometimes even in the face of a lifetime of illness.”363

  • Similarly, in New York, a mental health clinician with over thirty years of forensic and community mental health care experience in New York State told the Correctional Association:

Sometimes the [forensic mental health hospital] will say that a patient [sent from special housing units (SHU)] isn’t mentally ill, he is a manipulator, and they send him/her back to the prison, back to SHU. To me, labeling someone a “manipulator” is pretty useless. If there is a secondary gain issue, our job is to talk about it, to find out what’s really going on. There are clinicians who will tell you that eating feces isn’t a mental illness but a behavior problem (in some cases). Well, to me, eating feces certainly isn’t normal behavior. Our job is to find out why the inmate is acting abnormally and how to best treat him/her from a clinical perspective.364

  • A prisoners’ lawsuit filed against the Georgia Department of Corrections in March 2002, alleges abuse and neglect of seriously mentally ill prisoners at the high security Phillips State Prison.365 Among the allegations, prisoners claim the prison has systematically ignored the mental health issues of prisoners who engage in acts of self-mutilation, tending to view self-mutilation as a gesture by manipulative prisoners seeking attention, or looking to be removed from the unpleasantly harsh environment of a maximum security prison, rather than as a symptom of bona fide mental health problems. In addition, the lawsuit alleges that prisoners are routinely disciplined for their acts of self-mutilation. The Georgia Department of Corrections did not return phone calls from Human Rights Watch requesting a response to the allegations contained in the lawsuit.

  • In 1997, the behavioral clinician at Indiana’s Maximum Control Facility responsible for screening prisoners requesting a meeting with the prison psychiatrist, routinely refused to refer the prisoners because he believed that they were malingering. Thus, for example, he ignored a written request to see a psychiatrist by a prisoner who stated that he had a history of schizophrenia and needed to be put back on his medications because he was becoming increasingly suicidal and psychotic. Without ever having met with the prisoner or reviewing his records, the clinician told Human Rights Watch that he thought this prisoner was malingering and was not a schizophrenic.366

  • The complaint in the Reickenbacker v. Foster lawsuit in Louisiana alleges that prisoner D.N. “was written up by a social worker for violation of the aggravated malingering rule… because the social worker did not think his condition was ‘life threatening.’” The complaint alleges that at Hunt Prison, “manifestations of mental illness, such as repeated shouting or screaming or throwing objects in a cell are mistakenly and deleteriously diagnosed as ‘behavioral problems’ which are addressed by imposing discipline, not treatment.”367

  • In Washington, Janet Schaeffer told Human Rights Watch of how one prisoner at the Washington Correctional Center for Women was on the mental health roster, and was known to bounce between extremes of depression and mania. The mental health staff began treating her and counseling her. “The treatment was going very well,” Schaeffer told Human Rights Watch.368 “She started to lose weight, which was important because she was a diabetic. She came out of a very deep depression.” But then, Schaeffer continued, the prisoner witnessed some aggressive behavior between two other prisoners which triggered memories of her own crime — she was in prison for harming one of her children — throwing the prisoner back into an extremely deep depression. At that point, the prison’s mental health teams were rejigged, and the prisoner was assigned a new therapist. The new therapist, lacking knowledge of the prisoner’s history, immediately determined that she was faking her symptoms. “She was seen as somebody who was more dramatic than she needed to be, playing up her symptoms, or somebody who just needed to snap out of it,” Schaeffer stated. “The women [in the prison] were generally seen as manipulative as a group. Very few were really seen as mentally ill. The culture is ‘you’re being manipulated.’” Shortly after being assigned to the new, skeptical therapist, the prisoner set herself on fire.

A clinical bias toward assuming prisoners are manipulating or malingering may be the product of working too long without enough support in a professionally difficult environment. In his book Prison Madness, Dr. Terry Kupers suggests that many correctional mental health staff suffer from “burnout;” they feel exhausted, cynical, ineffective, and wish they could find work elsewhere. The more burned out staff become, the harder it is to be caring and conscientious. Kupers believes staff morale is weakened because mental health services are underfunded, understaffed, and “sadly lacking,” compared to the huge number of prisoners with serious mental health needs. He also points to the difficulty many competent mental health staff have with being subordinate to security staff, and having security decisions override and undercut their treatment efforts. Dr. Jeffrey Metzner suggests that continuing education and training of prison mental health staff will not only assist professional growth, but help prevent burnout. He also notes that the “use of part-time consultants can decrease the negative aspects of institutionalization, such as less creative thinking and decreased use of common sense impacting full-time staff.”369

Medication as the Sole Treatment

To facilitate recovery and the alleviation of symptoms of mental illness, mental health treatment in prison, as in the community, should include a variety of mental health therapies, should be multidisciplinary and eclectic in nature, and should be provided in a manner consistent with generally accepted mental health practices.370 The treatment should reflect an individualized written treatment plan for each mentally ill offender, taking into account life history, psychiatric diagnoses (before and after incarceration), and other factors. It should not be limited to simply alleviating immediate symptoms through psychotropic medication. Yet, “staff at many correctional facilities have overrelied on the use of psychotropic medications and, in many cases, sedative-hypnotic medications, simply to pacify and to control inmates with mental illness and others believed to be disruptive.”371 The court in Ruiz v. Estelle expressly noted that simply providing medication did not suffice to meet prison obligations to provide mental health treatment.372 The American Psychiatric Association includes among the essential services that should be provided as part of prison mental health treatment: “[s]upportive and informative verbal interventions, in an individual or group context as clinically appropriate;” and “[p]rograms that provide productive, out-of-cell activity and teach necessary psychosocial and living skills.”373

The need for varied therapeutic and life-skills enhancing interventions depends, of course, on the individual’s symptoms and diagnosis. A report on mental health by the U.S. Surgeon General’s office, for example, argued that for schizophrenia, a multifaceted treatment approach is essential. “Effective treatment of schizophrenia extends well beyond pharmacological therapy: it also includes psychosocial interventions, family interventions, and vocational and psychosocial rehabilitation.”374 While many prison systems have begun implementing diverse approaches for treating mental illness, most still over-emphasize medication. They do not provide sufficient resources for non-medication therapy, counseling, and a range of supportive structures for prisoners who do not need (or no longer require) hospitalization. In failing to do so, prison mental health staff fail to address the prisoners’ needs. They also miss an important opportunity to serve the public interest by taking advantage of the time prisoners are in prison to provide them with the cognitive and life skills enhancement that will increase the likelihood of a successful reentry into society following release from prison.

As Metzner told Human Rights Watch, the problem with most prison mental health services comes after mentally ill prisoners have been identified.

What do they do with them? That’s a common problem across states. Most psychiatrists’ roles are limited to medication management due to resource issues. The amount of psychotherapy available is very limited. There aren’t enough qualified people, or you might have a bunch of mental health clinicians without proper qualifications.375

Prisoners suffering from schizophrenia or other illnesses with psychosis, in particular, are unlikely to receive the intensive interventions necessary to help them learn how to better function in society, or even how to take care of their most basic personal hygiene and everyday living needs. “Although medication has a significant role to play in controlling psychotic symptoms, it cannot teach a patient the skills to acquire friends or a job, or to live in the community,” wrote Marnie Rice and Grant Harris, of the Pentanguishene Mental Health Center. “Nor can it teach patients how to take it [the medication] consistently and regularly. Other forms of rehabilitation, such as behavior therapy, skills teaching, and family therapy, are necessary in combination with medication.” 376 In other words, while medicating prisoners suffering from schizophrenia is likely to control their most obvious symptoms, it is unlikely to help those individuals learn to live, and cope, with their illnesses over the long-term either in prison or outside the prison walls.

According to Kupers:

The adequacy of mental health services cannot be measured solely in terms of staffing levels or the number of prisoners who receive mental health treatment, with or without medications. Adequate mental health treatment requires the availability of a trained clinician to develop a trusting relationship with a patient in a setting that permits privacy, where confidentiality is respected so that very personal themes can be explored and worked through. Adequate mental health treatment requires a variety of treatment modalities, including but not limited to crisis intervention; psychotropic medications as needed; the availability of a certain number of group activities such as group therapy, psycho-educational groups, facilitated socialization or recreational activities, and psychiatric rehabilitation groups that involve psycho-educational programs, training in the skills of daily living and medication compliance; admission to an acute psychiatric hospital as needed; social work outreach to family members as needed; and after-care planning so that the disturbed individual is not returned to the environment that caused a breakdown but rather is provided with the ongoing care and social supports needed to sustain his mental health. 377

Kupers observed that suicidal prisoners at Wisconsin’s supermax prison in Boscobel were often treated solely with medication, and that “the most often prescribed type of medication in suicidal crises — i.e., antidepressants — take between two and three weeks to reach full effect, so that they are not very useful in the acute situation.”

There is scant information publicly available that addresses the nature and quantity — much less quality or effectiveness — of the mental health services prisoners receive nationwide. The Bureau of Justice Statistics (BJS) reported that as of June 30, 2000, one in ten state prisoners receives psychotropic medications, and one in eight were in mental health therapy or counseling programs. While these data might be interpreted to suggest that more prisoners receive non-medication treatment than medication, they are too summary to provide useful insight into the nature, quantity, and length of time of the mental health counseling services purportedly provided. We are aware of no data that provide for any prison system a breakdown of the kinds of non-medication therapy provided, the amount of time that prisoners spent in such different therapy modalities over a given period of time how many prisoners had access to such therapy in given period of time, reasons why prisoners left the mental health caseloads, etc. For example, a complaint Human Rights Watch has received in every supermax we have ever visited and which has been raised in virtually every lawsuit filed by supermax prisoners addressing mental health services, is that “therapy” or “counseling” consists of no more than a mental health professional passing by the cell front periodically, asking a prisoner with a mental illness how he or she is doing and then proceeding down the row. Yet states may well include such prisoners among their statistics about how many prisoners receive counseling.

Our research suggests that in many prisons, access to mental health interventions other than medication is extremely limited in quantity and quality. This is especially true regarding long-term psychosocial interventions for seriously mentally ill prisoners living in the general prison population. “It’s commonly not available to all the people who need it,” Dr. Jeffrey Metzner reported to Human Rights Watch. “If you’re in general population, a small percentage will need it, but it’s limited. The limitations have to do with space and with staff resources — whether you have enough mental health clinicians.”378 In specialized residential treatment units and other intermediate care programs, there is far more access to modalities of treatment beyond medication, but such programs typically can serve only a very small number of prisoners. (See discussion below, chapter X).

  • Dr. Kathryn Burns, a psychiatrist with extensive correctional experience, reviewed mental health treatment records of prisoners at Phillips State Prison in Georgia at the request of plaintiffs in Fluellen v. Wetherington. Although the prisoners she reviewed were classified as requiring and receiving residential unit treatment and crisis stabilization services, the records revealed a:

dearth of structured therapeutic activities [which are] a hallmark of residential mental health care in correctional facilities. Mental health treatment is more than simply the prescription of psychotropic medication. Participation in therapeutic activity permits inmates with serious mental illnesses the opportunity to improve their socialization and communication skills, develop additional coping skills, and engage in meaningful activity which is otherwise often unavailable to them in prison because of their illnesses. At Phillips State Prison, recreational and therapeutic activities were provided less often than twice weekly rather than several times daily for five or more days per week. In addition, often when activities were conducted, the inmate files frequently contained a notation that the inmate could not participate as he was on “lock down status.”379

  • State investigators from the Indiana Department of Mental Health studied mental health services at Putnamville Correctional Facility. They found that eight of twelve prisoners whose health records they examined were taking psychotropic medications but had no individualized treatment plans. The investigators found that the prison psychiatrist routinely prescribed medications over the phone without first examining his patients, and discovered one prisoner with toxic levels of the prescribed drug lithium in his bloodstream.380

  • In the final report issued in July 1999 by the Special Master overseeing the New Mexico prison system, the monitor reported that, while the state appeared to be in compliance on most issues, “in only 21 (62%) of the files in which activity levels were addressed…did the staff implement the prescribed activity level.”381 In other words, in practice, the state was failing to implement its own recommendations regarding programming for seriously mentally ill prisoners. The report also found that between August 1998 and January 1999, the number of activities available to prisoners actually decreased from 16 to 13.382

  • In Pennsylvania, despite good mental health protocols having been developed in recent years, seriously mentally ill prisoners housed in what are termed the Special Needs Units are supposed to be offered thirty-five hours of programming per week. However, prison administrators include two hours per day of regular exercise, meal times, and the time prisoners are out of the cells working prison jobs as part of the “programming.” If these hours are excluded, it turns out that seriously mentally ill prisoners in fact receive only about four or five hours of actual mental health therapy and group programming per week.383

  • In Mississippi’s enormous Parchman prison (officially known as the Mississippi State Penitentiary), one part-time psychiatrist and two university psychiatrists put in a total of forty hours per week of psychiatric coverage, much of it tele-medicine-based. The prison also has five psych-assistants and four case managers. Its one psychologist position was, as of May 2003, vacant. This paltry staff is responsible for the mental health needs of a prison population of well over five thousand prisoners spread across buildings and land that take up a massive eighteen thousand acres.384 The university psychiatrists never visit the prisoners in person, and have sessions via teleconferencing about once every three months, for about ten minutes. Other than medications, few prisoners have any access to counseling or therapy, and if they do it is usually for only a few minutes a month. Psychiatrist John Norton admitted to never having seen the facilities at most of the institutions for which he does tele-medicine.385 Norton’s patients are, he told Human Rights Watch, “medication only. A chronic schizophrenic who’s doing well on meds may never go to counseling.” Like many of the more cash-strapped prison systems, Mississippi does not mandate that seriously mentally ill prisoners have access to a minimum numbers of hours of counseling per week. The state’s other prisons have equally low levels of staffing and equally poor access to counseling and group therapy: at Central Mississippi Penitentiary, 2,500 prisoners are serviced by thirty-two hours a week of psychiatric coverage, one non-Ph.D.-level psychologist and ten lower level case managers, psychiatric evaluators and psych assistants. Meanwhile, the Southern Mississippi Penitentiary currently has no psychiatric coverage at all. If prisoners are deemed to need anything beyond medication, they have to be bussed to the Central Mississippi facility.386 Linda Powell, director of utilization review and case management at the University of Mississippi Medical Center, which provides medical and mental health services inside the prisons, stated to Human Rights Watch that Mississippi’s prisoners “have very little group therapy.”387

  • In Hawaii, a state in which almost 20 percent of the prisoners are on psychotropic medications, the Bureau of Justice Statistics found that fewer than 6 percent of prisoners were receiving any form of therapy or counseling.388

  • At the Washington Correctional Center for Women, many of the prisoners complain that they have only minimal access to therapy and regular group programs, but that they are medicated at the drop of a hat. Prisoner O.T. told Human Rights Watch:

They need to hire more counselors and more therapists and not [use] so much medication. They med people up. If they counseled them, they might not need the medication. But they don’t have the funding for it. People walk around zoned out. They’re just not there.389

Many other prisoners echoed her views. While Human Rights Watch recognizes that patients are not clinical experts on appropriate dosages of medications, the fact that many prisoners complained of being powerfully medicated without adequate counseling leads us to believe that this should be an area of ongoing concern within the prison system. This problem was also referred to by Mike Robbins, Washington’s former Acting Mental Health Director, who acknowledged that in a prison mental health setting too often the psychiatrist (the doctor who medicates) serves as the primary responder to, and care-giver for, mental health needs rather than the psychologist (the clinician who offers therapy and counseling). In essence, this means that mental illness is dealt with first and foremost, and oftentimes exclusively, through medication.

Lack of Confidentiality

Lack of confidentiality during prisoner meetings with mental health staff is widespread. In a prison context, confidentiality is defined as sound privacy rather than visual privacy, in other words, whether a prisoner can talk to mental health staff without being overheard by correctional officers and other prisoners. The lack of confidentiality is particularly acute in facilities or units where prisoners are kept in their cells twenty-four hours a day.

In numerous facilities that Human Rights Watch visited while researching this report, locked-down or segregated prisoners stated that their main contact with caseworkers and psychologists was in the form of cell-front visits. Because of the lack of adequate numbers of security staff needed to move such prisoners from their cells into settings in which such private counseling can take place, and because of a tendency of prison mental health staff to downplay the importance of confidentiality, all-too-often these prisoners are provided with cell-front sessions that can be overheard by everyone on the block. Many prisoners have told us that their conversations with mental health staff are limited to cell-front exchanges in which they refuse to say anything personal because of the lack of privacy.

“It’s a common problem,” Dr. Jeffrey Metzner told Human Rights Watch. “It’s easy to become institutionalized as a mental health provider. I go to lots of prisons where we make it an issue because they don’t have adequate sound privacy.”390

For example, in October 2000, the National Commission on Correctional Health Care wrote an accreditation report on the supermax prison in Wisconsin and found that:

Officers are with the inmates during all examinations. Many of the PA [physician assistant] and physician sick call visits are done through the cell door. The officers do step back from the door; however, other inmates on that range can hear the exchange of information. Neither auditory nor visual privacy is maintained. The Standard [regarding confidentiality] is not met.391

According to a federal district court, on Unit 32 of Parchman Prison in Mississippi, “[w]hat mental health services are provided generally take place at the inmate's cell within hearing of other inmates and guards. This results in the failure of inmates to tell the mental health specialists anything of substance.”392 The court ordered the Mississippi Department of Corrections to ensure that, “All inmates receiving mental health counseling or evaluation shall meet with the mental health professionals in a private setting.”393

Those inmates diagnosed with psychosis and severe mental health illnesses shall be housed separately and apart from all other inmates. The medication levels of all inmates receiving psychotropic medications shall be monitored and assessed in accordance with appropriate medical standards.


The development of powerful drugs for the treatment of mental illness has enabled a revolution in mental health care in the United States, including in U.S. prisons. The newer types of psychotropic medications have increased the alleviation of symptoms and increased the prospects of recovery for people with mental illness and with far fewer and less debilitating side effects than older medication. Because they increase the likelihood that the prisoner will adhere to a treatment plan, they can reduce long-term mental health treatment costs. Yet many prisons systems limit use of the newer medications because of their cost. The unique context of prisons imposes certain constraints on the delivery and monitoring of medications.

Proper Medication

In some states, because of inadequate mental health staffing, medication is prescribed without an adequate evaluation of the prisoner and the development of an individualized treatment plan. For example, experts examining mental health care in Alabama prisons noted:

Anyone receiving prescription medication must be assessed by the prescribing psychiatrist on a regular basis to determine the effectiveness or lack thereof and potential side effects. There are numerous instances throughout the Alabama prison system in which psychiatrists prescribe medications for periods of up to three months without any face-to-face contact with the recipient. The nursing staff are medical/surgical type nurses and do not document inmate response to prescribed psychotropic medications…. [M]ental health records reveal instances in which inmates experiencing psychiatric difficulties are prescribed psychotropic medication by a psychiatrist in a remote location who has never seen the inmate. A nurse, with no experience or training in the signs or symptoms of mental illness, relays the information on which the psychiatrist bases his prescription decision. There is no documentation as to the effectiveness of the prescribed medication and no planned follow-up.394

The Department of Justice’s investigation of mental health care in the Wyoming State Prison uncovered many deficiencies, including inappropriate medication. Medication was sometimes inappropriately withheld; prisoners were regularly denied access to mental health staff; prisoners in administrative segregation routinely failed to receive prescribed medications; and psychotropic medications were often prescribed by physicians lacking mental health expertise. This, “resulted in incorrect or dangerous choices of medications, inappropriate polypharmacy, improper and abrupt discontinuances of addicting psychotropics and occasional inappropriate use of emergency medications.”395

New and more effective medications, such as selective serotonin reuptake inhibitors (anti-depressants) and the atypical antipsychotics are now available for the treatment of mental illness. Unfortunately, these medications are usually much more expensive than older ones. Because of their costs, the “[n]ewer medications…are not used as frequently in prisons and in jails as they are in the general community.”396 Some prison systems have open formularies, allowing psychiatrists to prescribe the most up-to-date medications.397 But others, such as Mississippi’s, still mainly prescribe older medications to their seriously mentally ill prisoners; they cut costs by prescribing the more expensive atypical drugs to only a minority of their seriously mentally ill prisoners.398 Some very effective drugs such as Chozaril are rarely used in prisons because they require expensive work-ups and continual blood monitoring.

According to Patricia Perlmutter, the lead attorney representing plaintiff prisoners in a lawsuit about New Jersey’s prison mental health services, until the state agreed to settle the case in 1999, “the more modern medications weren’t available. The prisoners would suffer side effects, then they would refuse their medications.”399 Dr. Dennis Koson plaintiffs’ expert in the New Jersey case, reported that:

Continuity of care is compromised when inmates arrive in the system on “non-CMS [Correctional Medical Services, the private correctional health care provider] formulary” drugs and are taken off them. For example, after many drug trials and a very turbulent psychiatric history in administrative segregation, John Doe 137 was hospitalized at the Forensic Hospital and finally stabilized on Olanzapine, a new and very effective antipsychotic agent that is off-formulary. He stabilized very quickly on the drug and was returned to the prison system on July18, 1997. An on-call psychiatrist was called and, in a telephone order, discontinued the Olanzapine without examining the patient. John Doe 137 became increasingly psychotic and resistant to medication treatment (although he was taking it) which culminated in the use of the involuntary medication process in January 1998.400

Attorney Perlmutter told Human Rights Watch that Koson’s findings indicated that “the failure to keep the patient on the more effective and expensive medication led to this patient's decompensating and requiring more intensive services, with a cost both to the patient's health and to the prison's management of the inmate.”401 Under the settlement in the case, monitors now approve the formulary so it is no longer restricted to the older generation of drugs.

Limited access to newer medications was among the problems cited by medical and psychiatric experts reviewing mental health services in Texas prisons in 1998 and 1999. As one expert noted:

Medication when administered is in many cases inadequate as patients I interviewed on the active caselog demonstrated or complained of on-going symptoms or signs of mental illness or medication-induced movement disorders. Given the armamentarium of medication available including the newer atypical anti-psychotics, I would expect to find the patients having more symptom amelioration than was the case. The medications in use were mainly of the older and less expensive variety. Newer medications such as Risperidone, Olanzapine and Clozaril are not on the formulary and, although the physician can request permission to use an off-formulary drug, there are factors at work which obviously dissuade use of these drugs…In the face of the poor response of a number of the patients to the formulary — approved medications, I believe good medical practice would call for clinical trials of alternate medication, at a minimum. If the goal of the managed care system is to save money, it is doing so at the cost of rendering inadequate and potentially harmful care to the patients.402


Prisons have their own unique rules for how and when medications can be delivered; rules which may not designed to meet the needs of patients. To prevent hoarding of medications and to ensure the medication is in fact taken, most prisons deliver medication to prisoners in single doses. In many prisons, prisoners must spend an hour or more standing in line two or three times a day to receive their medicine — an inconvenience which deters many from continuing with their medication regime. Some prisons have separate lines for psychotropic medication, which identifies the prisoners in those lines as mentally ill. Some prisoners refuse to take medication because they do not wanted to be identified as “bugs” — prison slang for prisoners who have mental illness.

Some prisons require prisoners to take medication in the early evening that should be taken just before a patient goes to sleep. Taking the medications early either causes the patient to fall asleep in the late afternoon, or to remain awake, and increasingly anxious, before the medication takes effect. At the California Institute for Women, in the southern California town of Corona, a psychiatrist at the prison told Human Rights Watch that if prisoners are given medications at five-thirty p.m., they are likely to still be awake two or three hours later, and that these medications, at high dosage, if not followed by sleep, can cause patients to suffer considerable levels of anxiety.403 “There are no night-time [medication deliveries],” a psychologist at the prison reported. “There should be. A lot of psychiatrists write prescriptions for drugs to be taken just before they go to sleep. But they’re taking their meds at 5 or 6 o’clock — and then they fall asleep at 7 o’clock and wake up at 3.”404

In most prison systems, trained nurses distribute the medications; but in some, correctional officers with no medical background are given this responsibility. Todd Winstrom, an attorney with the Wisconsin Coalition for Advocacy, told Human Rights Watch that in some Wisconsin prisons, guards, rather than nurses, both distribute medications and are responsible for re-ordering the medications when a prisoner’s supplies run low.

That’s their policy. It’s standard procedure. It’s spoken of as an article of faith that guards don’t like doing this. They don’t regard it as their job. Between low interest and lack of training, errors are pretty common. Sometimes they just allow the medications to run out. It’s very common to see a lapse before refills are ordered.405

Winstrom believes that the problems would be minimized if nurses were in charge of the medications. “They understand the importance of this and they have the training. Nurses would be afraid of the consequences to their professional license.”406 In Mississippi, prison psychiatrist John Norton told Human Rights Watch that “specially trained guards,” rather than nurses, distribute psychotropic medications to prisoners.407

Distribution of medications by correctional officers is troubling for other reasons. It raises both privacy concerns (non-medical personnel gaining access to confidential medication information on prisoners) and also heightens the risk of inappropriate delivery (medically untrained staff may unknowingly distribute the wrong medication, or the wrong dosage, or distribute it at the wrong time, not realizing that many drugs must be administered at roughly the same time every day). Such practice is in clear violation of procedures developed by the National Commission on Correctional Healthcare (NCCHC), the American Correctional Association (ACA) and other accreditation organizations.

Medication Discontinuity

The sudden removal of a person from strong anti-depressants or anti-psychotic medications can lead to serious withdrawal effects, including changes in blood pressure and heart rate, irritation, anxiety, sleep-disorders, nausea, paranoia, even, at times, psychosis. Mental health care providers in the free world take care to wean their patients off of these medications slowly. “If you don’t,” psychiatrist Dr. Terry Kupers explained to Human Rights Watch:

they can get neuro-physiological rebounds: with the anti-depressant Paxil, they get dizziness, seizures, faintness, agitation, insomnia, anxiety and panic attacks. When someone is on anti-psychotic medication, if you discontinue that precipitously they’re very likely to have a relapse of the psychotic condition.408

In prison, however, the sudden withdrawal from powerful medications is not uncommon. When prisoners are moved from jail to prison, or from one prison to another, any medication they were on will usually be discontinued and they must see a new psychiatrist to have a decision made as to what medications they will receive. In under-staffed correctional mental health systems with few resources devoted to record-keeping and the tracking of mentally ill prisoners, prisoners can wait days, even weeks, to see a psychiatrist in the new institution and to be placed on medication again. Security can also disrupt medication delivery: for example, entire units or wings of prisons are placed for days or weeks under lock-down because of a disturbance. The lockdown means prisoners cannot stand in line for their medication — yet, the prison may not have systems in place for ensuring delivery of medications to individuals in their cells.

Examples of problems in timely delivery of correct medication include the following:

  • In South Carolina, investigators found that prisoners at Lee Correctional Institution routinely had to wait days for needed medications.“Medications were considered timely if they were available within two days of when the inmate needed them,” they reported. “Approximately 46% (24 of 52) of the medications that we reviewed were not administered within these time periods; three of these medications appeared not to be administered at all.”409

  • In Mississippi, Dr. John Norton, a University of Mississippi psychiatrist contracted to provide a few hours a week of psychiatric services for the Department of Corrections, states that prisoners frequently wait a week or more to be put back on medications after having been withdrawn from the medications when they were removed from their previous institution. “I’ll see them within a few days,” he asserted. “There definitely can be a gap in medications of a few days. If they come in over the weekend, there’ll definitely be a gap. I haven’t seen many go without meds for over a week. It’s not optimal. But the volume is huge.”410

  • Todd Winstrom, an attorney with Wisconsin’s Coalition for Advocacy, described to Human Rights Watch some of the medication problems at specialized mental health unit at Taycheedah women’s prison. Over the Labor Day weekend in 2001, Winstrom’s clients told him that the prisoners did not receive prescribed Benzodiazepine-category drugs such as Lorazapam. “Supplies had been allowed to run out,” Winstrom asserted. “And new ones had not been ordered. I’ve looked at other cases and I’ve found that this isn’t uncommon.” Abrupt withdrawal from this medication, he stated:

can cause serious medical problems — convulsions, seizures, episodes of delusions and dementia, changes in blood pressure and heart rate. In extreme cases it can be fatal. One woman exhibited these symptoms. Non-medical staff made the decision she was malingering and placed her in isolation.411

Winstrom also alleged that medical charts for this woman indicate that in a one-month period she was denied 40 percent of her medications. As a result, her behavior worsened, and she began accumulating disciplinary tickets. In another instance, Winstrom told Human Rights Watch that medical records indicate a female prisoner received only 50 percent of her prescribed medications over a twelve-month period.412

  • In California, mentally ill prisoners who are housed in the general population reported interruptions in their medication. For example, one prisoner, D.F., at Corcoran State Prison stated that he “ didn’t get [his] medications for six days,” after he was transferred to the prison from another one. D.F. alleged that the medical discontinuities occurred every time he was transferred from one facility to another. “They take your medication,” he explained. “At the new institution you have to go through the medical thing to get your medication. You wait up to five to seven days to get your medication. By then you’re too far gone to know anything. By then, man, it’s not cool.”413 At California State Prison at Sacramento, another prisoner, J.G., told Human Rights Watch that in the general population he’d sometimes miss his medications for a couple days after his prescription had expired.414

Abrupt withdrawal from medication can also lead to prisoners acting out and becoming disruptive. According to an investigation into Wyoming State Penitentiary by the Department of Justice:

In several cases we reviewed, inmates in general population predictably became problematic after [Wyoming State Prison] inappropriately and suddenly withheld long-standing dosages of benzodiazapines. The discontinuation of medication resulted in irritability, which led in turn to charges of threats and abusive language, and resulted in punitive detention placements in administrative segregation….415

Inadequate Monitoring of Medication Side Effects

The first generation of anti-psychotics, including drugs such as Thorazine and Haldol, which are still commonly used in prisons, can cause a Parkinson’s-like illness known as Extra Pyramidal Syndrome (EPS). Patients placed onto these drugs can develop the symptoms of EPS almost immediately: excessive saliva, a powerful clamping of the mouth, severe back and neck cramping, and spasms.416 The syndrome can be treated by the use of Cogentin and Artane medications. A more serious side effect associated with early anti-psychotics is Tardive Dyskinsia, essentially a degenerative muscle-tic and tremor that begins in the face and spreads throughout the entire upper body. There are no medicines to counter this condition. In many prison systems that still prescribe the earlier and cheaper anti-psychotics, severely ill prisoners are put in the uncomfortable position of having to choose between getting their illness under control, but developing Tardive Dyskinsia, or opting not to take the anti-psychotics and thus risking a psychotic break. More recent anti-psychotics, while not producing Tardive Dyskinsia in patients, nevertheless have their own host of side-effects. Atypical anti-psychotics such as Xyprexa, Resperdal, and Seroquel can cause obesity, impotence, heart problems, and passivity. Newer anti-depressants can cause headaches, tremors, and even confusion.417

All of these symptoms need to be carefully monitored. Our research suggests, however, that in many prisons the monitoring effort falls far short. For example:

  • In Alabama, outside experts who evaluated the state’s prison system reported that:

[T]here are several psychotropic medications which require periodic blood level monitoring and laboratory studies to check on liver, kidney and thyroid functioning to ensure the medications are not causing damage to those organs. [Yet blood] work is not routinely ordered on ADOC [Alabama Department of Corrections] inmates. Serum levels are not checked to ensure the inmate is receiving an appropriate dosage of medication. Subsequently, behaviors are attributed as being willful or manipulative rather than understood as symptomatic of untreated or improperly treated mental illness.418

  • In New Jersey, Dr. Dennis Koson reported that :

Inspections and chart reviews uncovered inmates experiencing anything from mild to sometimes severe side effects of their medications that went unaddressed for significant periods of time. John Doe #136, for example, was on various psychotropic medications that resulted in dry mouth, dizziness on standing, and urinary retention. Similarly, John Doe #1, was prescribed intramuscular Prolixin, an antipsychotic medication, and noticed tremors which were a side effect of the medication. His psychiatrist then prescribed oral Prolixin, the very drug which had caused the problems. Some side effects I noted were severe and also represented irreversible neurological syndromes.419

  • When the autopsy results came back on Timothy Perry after he had died in a Connecticut prison (see above case study on Perry), they showed that he had Thorazine in his blood, despite the medical record indicating that he was both asthmatic and allergic to Thorazine, and that he was at risk of having a central nervous system shut-down if given the drug.420

  • In the segregation unit at Robertson prison in Texas, forensic psychologist Keith Curry found a:

37 year old man with chronic paranoid schizophrenia…in a floridly psychotic state despite receiving long-lasting injectable antipsychotic medication once a month. He presented with severe Parkinsonian side-effects from his medication. He reported that mental health staff conducted cursory rounds once a month, but did not inquire about medication side-effects…. Two other inmates taking antipsychotic medications appeared to be psychiatrically stable, but presented with moderate to severe Parkinsonian side-effects that were not being adequately addressed. These side-effects are painful and debilitating, requiring immediate medical attention.421

Protecting Prisoners on Medication from Heat Reactions

Heat related illnesses occur when the body’s temperature control system is overloaded and body temperatures rise. The risk of heat related illnesses increases when air temperatures exceed ninety degrees, especially with high humidity. Persistent heat stress may lead to heat stroke — a severe medical emergency that can damage the brain and other vital organs, and causing death or permanent disability of emergency treatment is not provided. Many commonly prescribed psychotropic drugs, including Thorazine and Haldol, as well as certain anti-depressants, render patients particularly sensitive to hot weather conditions and heat stroke. They limit the body’s ability to cool itself down by sweating and suppress the brain’s ability to perceive temperature changes, preventing the patient from initiating compensatory behavioral changes.422

Prisoners on psychotropic medication are at particular risk of heat-related illness because most live in prisons that are not air-conditioned and have poor ventilation. Although air-conditioning can be a lifesaver, not a luxury, in its absence prisoners must have access to fans, showers at least once a day, ample supplies of drinking water at all times, and ice. These basic and humane precautions — important for all prisoners — are especially important for prisoners on certain medications. However, some prisons ignore them.

  • In the prison at Parchman, Mississippi, the only way to keep hordes of bugs from infesting prison cells is to shut the windows. Closing the windows during the sweltering summer months in the Mississippi Delta creates intense heat in the concrete cells in which mentally ill — as well as non-mentally ill — prisoners live. Prisoners at Parchman are denied adequate supplies of water during the summer months, leading, in some extreme cases, to prisoners drinking water from out of their toilet bowls in attempts to cool themselves down. One mentally ill prisoner on the medication Remeron, T.Y., told an outside expert on heat stroke that in late June 2002:

We were just without any water on the Unit for almost a week. The sewage has been backed up in every cell and people started to throw their wastes out into the hall…. I tried to stay hydrated with the water they bring at meals, but that’s the only liquid we got all day: a cup of coffee at breakfast; a small glass of juice at lunch; and a small glass of water at dinner. It wasn’t enough for me to take my medicine. And it wasn’t enough to live on, especially in this heat. I felt myself drying out and getting weaker. My mouth was cracked and my throat was rough.423

An emergency medicine expert, Dr. Susi Vasallo, visited Parchman on behalf of plaintiffs in a class action lawsuit to render an opinion concerning risks of heat-related illness on Unit 32, the death row at the prison.424 She found that all of the death row prisoners have one or more high risk factors for heat stroke. Nevertheless, the physician serving Unit 32 was “surprised to learn of the risks of heat illness” and had never considered whether the medication the prisoners were taking put them at great risk for heat related illness.

Dr. Vasallo, who describes herself as a Texan who loves the heat, entered one of the prisoner cells when the afternoon sun was shining on it and described it as the same “as getting into a car parked in the hot Texas sun and sitting with the windows rolled up.” She found many of the prisoners had no access to fans, infrequent access to showers, and sometimes even limited access to water. They were not allowed to shade their cell windows from direct sunlight, and in the outdoor exercise pens, there was no shade from the sun.

In May 2003, a federal district court found that the ventilation in Unit 32-C:

is inadequate to afford prisoners a minimal level of comfort during the summer months. While temperatures obviously run high during the summer months in Mississippi, inmates on lockdown status, such as the inmates on Death Row, must rely on the Mississippi Department of Corrections for minimal relief. The probability of heat-related illness is extreme at Unit 32-C, and is dramatically more so for mentally ill inmates who often do not take appropriate behavioral steps to deal with the heat. Also, the medications commonly given to treat various medical problems interfere with the body's ability to maintain a normal temperature.425

The court ordered prison officials to take heat measurements several times daily from May through September and ordered them to ensure each cell has a fan, and that prisoners have access to ice water and can take daily showers when the heat index is ninety degrees or above. Alternatively, the officials could simply provide fans, ice water, and daily showers during those months without taking heat measurements.

  • At the California Institute for Women, in the desert climate of Southern California, one forty-five-year-old prisoner, D.O.F., currently taking lithium and Resperidal to stop her from hearing voices and acting on those internal stimuli, reported that while she had good access to counselors and to psychiatrists:

the only thing I’d ask is that we get our heat fans back. I get sick. I feel faint, light, nauseous, listless. I can’t operate, I can’t function. It happens every day as long as it is hot. It gets hot. Sweat just pours down your face, your body.426

  • Another seriously mentally ill woman at the same prison, E.F., has been in-and-out of correctional settings since 1980, when she hit a stranger over the head with a bottle in San Francisco’s Chinatown. “I thought I’d tell China they shouldn’t mess with the United States,” she said in explanation. She is currently serving life without parole for a crime she committed while in a psychotic state. For her, too, the heat is one of her biggest concerns. “At first they gave everybody fans because it was so hot,” she recalls.

And then they never gave anybody fans and people would faint and get sick. It’s so hot sometimes you can’t bear it. Without a fan in the cell, it’s like a boiler house. People get faintish, nauseous, get dizzy, become irritable, don’t want to take their medications.427

  • According to the recent findings of a federal district court, the Julia Tutwiler Prison for women in Alabama, some of whose prisoners are mentally ill and taking psychotropic medication, is “extremely hot in the summer, and lacks needed ventilation, creating a stuffy, stagnant climate.”428 There is no air conditioning. The warden put large floor fans on some dorms, but the effect was “simply to move hot air around.” Other measures provided little relief from heat. Although there are ice calls twice a day, ice was sometimes not available at mid-day when the heat is at its hottest. There were no instruments to monitor the heat, so there was no way for officials to determine when the temperature exceeded ninety degrees and therefore, according to prison protocols, prisoners were entitled to additional ice, opportunities to shower, and increased access to drinking water. In disciplinary segregation, the climate was “like a desert.” There are only five fans for the seventeen cells in segregation.429

  • Dr. Jeffrey Metzner, a psychiatric expert retained by plaintiffs in connection with the Ruiz litigation in Texas, reviewed reports relevant to prisoners experiencing heat-related illnesses as part of his audit of Texas mental health care. He reported that between June 10 and July 30, 1998, at least sixteen prisoners experienced significant symptoms related to hyperthermia, three of whom died. One-fourth of the prisoners were receiving psychotropic medication and had a history of mental illness. One of the prisoners was a forty-seven-year-old man with a history of paranoid schizophrenia who was receiving Haldol and Congentin, when he died because of hyperthermia. Another prisoner who Dr. Metzner identified as having experienced heat-related problems exacerbated by psychotropic medications was sent to the hospital in June, 1998 with a 107 degree temperature. He had a complicated medical history including multiple sclerosis, diabetes, asthma, and schizophrenia. Like other Texas prisoners, he lived in a unit without air-conditioning, despite the one-hundred degree temperatures to which Texas summers soar.430

Inadequate Efforts to Ensure Medication Compliance

One of the most frustrating manifestations of serious mental illness is that frequently very ill individuals believe themselves to be fine, and often believe those who encourage them to take medications are involved in some form of conspiracy against them. Many also stop taking their medications because they are experiencing unpleasant side effects and their medications have not been adjusted in a timely manner. Mental health treatment providers in the community work constantly with their clients to ensure they continue their medication and to educate them about the importance of the medication. Yet, because prison mental health resources are stretched so thin, little effort is devoted to explaining the need for and nature of medication to prisoners.

When prisoners refuse to take their medications, little effort is devoted to coaxing them to change their minds. At most mental health staff may visit a prisoner’s cell front and briefly try to convince him or her to take their medications. If a prisoner who stops medications seriously decompensates and becomes a danger to himself or others, he may be involuntarily medicated on an emergency basis and may be sent to the prison’s mental health hospital or acute care unit where mental health staff can continue to administer medication involuntarily if certain legally-mandated administrative steps are followed. Yet, even in instances where involuntary medication isactually necessary because a prisoner is refusing to take or his or her medications and has, as a result, become dangerously psychotic, sometimes prison officials do not take the time to seek legal permission for this procedure. “I’ve seen it happen in Washington, and it happens for reasons that apply in other systems as well,” said David Lovell, of the University of Washington. “Lack of staffing can result in not having a routine, systematic, involuntary medication practice. Prisoners will simply vegetate or be put in Ag Seg [administrative segregation] or special housing.”431

Mental health staff may simply ignore prisoners who refuse medication or remove them from the mental health roster. For example, according to Patricia Perlmutter, the attorney who represented plaintiff prisoners in a suit against the New Jersey Department of Corrections:

If a prisoner refused medication, rather than try to reengage them in treatment, or offering alternative medicines or psychotherapy, the system was so short-staffed they would just strike your name from the mental health caseload. So the most seriously mentally ill wouldn’t show up on the caseload.432

Florida attorney Randall Berg told Human Rights Watch that between fifty and one hundred seriously mentally ill prisoners at Florida State Prison (FSP) stopped taking medications after the state decided to concentrate its most seriously ill offenders at that prison, and to move those not on medications to other (reportedly better) prisons.433 Prison mental health staff at FSP did not increase their monitoring of the seriously ill prisoners. Instead, when the prisoners stopped taking their medications, their status was downgraded from “S-3” to “S-2,” meaning that a psych specialist stopped by their cell only once a month instead of every week, and that they were seen by a psychiatrist only every ninety days instead of every thirty. Berg asserted that several prisoners decompensated and had to be transferred to crisis units to be stabilized after dropping their medications.

The problem of seriously mentally ill prisoners choosing to withdraw from their medication regimens is exacerbated in states which exclude prisoners on the mental health caseload from desirable programs. For example, in California, prisoners on medication for mental illness do not qualify for work furlough programs. According to social worker Marilyn Montenegro, who works with mentally ill women coming out of prison, “[work furlough] is a very desirable program, so the inmates stop taking their medications and a lot come to the program and the staff realize there’s something going on there. And the women say: that’s what I did to come here.’”434 Sue Burton, executive director of a small re-entry home for mentally ill women leaving prison in California also stated that “the women will deny themselves medical treatment, because they have to be medically cleared to get work-furlough.”435 Rick Jordan, the community involvement officer for Washington’s McNeil Island prison, sees a similar problem. “We have zero pre-release camp beds for people on psychotropic medications,” Jordan explained to Human Rights Watch. “It’s counterproductive to tell people you can go there if you’re not taking medications. People stop taking their medications in a usually vain attempt to get there. Then their behavior deteriorates.”436

296 Ruiz v. Johnson, 37 F. Supp.2d 855, at 906 (S.D. Texas, 1999).

297 Camille G. Camp and George M. Camp, Corrections Yearbook 2001: Adult Systems, “Snapshot: Mental Health and Counseling Staff on January 1, 2001” (Connecticut: Criminal Justice Institute, 2002), p. 177.

298 American Psychiatric Association, Psychiatric Services in Jails and Prisons, 2nd Ed. (Washington D.C., American Psychiatric Association, 2000), p. 6. The APA points out that this goal “is deliberately higher than the ‘community standard’ that is called for in various legal contexts.”

299 Ibid., pp. 7-8.

300 State of Washington Department of Corrections Final Report Health Care Facility Master Plan, DLR Group in association with Pulitzer/Bogard & Associates, L.L.C., 2000.

301 Human Rights Watch telephone interview with Harbans Deol, medical director, Iowa Department of Corrections, June 14, 2002.

302 Questionnaire was answered by Arkansas Department of Corrections’ mental health director Max Mobley.

303Letter to Wyoming Governor James Geringer from Bill Lann Lee, acting assistant attorney general, Civil Rights Division, U.S. Department of Justice, June 29, 1999.

304 New York State Office of Mental Health, Task Force on the Future of Forensic Services, Report of the Subcommittee on Prison Mental Health Services, pp. 9-11, January 31, 1997.

305 Minutes from Florida Correctional Medical Authority Mental Health Committee Meeting, March 23, 2001.

306 Ibid.

307 Human Rights Watch telephone interview, Joe Fitzpatrick, clinical director, Maine Department of Corrections, March 28, 2003.

308 Job Announcement advertised by the Virginia Department of Corrections Human Resources division.

309 Job listing posted on Available online at:, accessed on September 15, 2003.

310 York County School Division, Human Resources Department, Yorktown, Virginia. August 2003.

311 Human Rights Watch telephone interview with Randall Berg, attorney, Miami, Florida, April 21, 2003.

312 Tara Herivel, “Wreaking Medical Mayhem in Washington’s Prisons,” Prison Legal News, September, 1999. Herivel’s source for this was a deposition by Alice Payne, warden, Washington Correctional Center for Women, in the context of the lawsuit, Hallet v. Payne.

313 Coleman v. Wilson, 912 F. Supp. 1282 (E.D. California, 1995).

314 The California Department of Corrections mental health services budget has grown from $204,725,000 in 2001 to $245,598,000 in 2003. Human Rights Watch telephone interview with Terry Thornton, spokesperson for the California Department of Corrections, June 16, 2003. California’s prison population was 163,001 in 2000, and declined slightly to 162,317 in 2002. BJS, Prisoners in 2002, p. 3; and Allen J. Beck, Ph.D. and Paige M. Harrison, Prisoners in 2000 (Washington D.C.: Department of Justice, Bureau of Justice Statistics, August 2001), p. 3.

315 See table 2 above, Fiscal Year 2003-2004 Mental Health Care Budgets in State Departments of Corrections (DOC). For fiscal year 2003-2004, $245,598,000 is budgeted .Human Rights Watch telephone interview with Terry Thornton, June 16, 2003.

316 Human Rights Watch interview with Radu Mischiu, MD, psychiatrist, Administrative Segregation EOP, California Medical Facility, California, July 19, 2002.

317 Dr. Jeffrey Metzner, Memorandum, to Special Master J. Michael Keating, Office of the Special Master, December 11, 1998.

318 J. Michael Keating, Ninth Monitoring Report of the Special Master on the Defendants’ Compliance with Provisionally Approved Plans,Policies and Protocols, Coleman v. Davis, No. CIV S-90-0520 LKK JFM P, April 24, 2002.

319 Special Master’s Report Re Status of PSU and EOP Compliance with Health Services Remedial Plan, p. 5. Filed October 17, 2000.

320 The quote is taken from a summary of the audits published in the Report on the Current Status of Services for Persons with Mental Illness in Maine’s Jails and Prisons: 2002, Attachment One, The Citizen’s Committee on Mental Illness, Substance Abuse, and Criminal Justice and the National Association for the Mentally Ill, Maine, September 2002.

321 Human Rights Watch telephone interview with Joe Fitzpatrick, clinical director, Maine Department of Corrections, February 6, 2003.

322 Jeffrey Metzner, Cohen, F., Grossman, L.S., Wettstein, R.M: “Treatment in Jails and Prisons.” In: Wettstein, R., Ed.: Treatment of Offenders with Mental Disorders (New York: Guilford Press, 1998), pp. 211-264. Mental health professionals in the community typically face licensure, certification, or registration requirements.

323 Dr. Jeffrey Metzner quotes this study in his article “Guidelines for Psychiatric Services in Prisons,” Criminal Behavior and Mental Health (1993), vol. 3. Dr. Metzner sources this information to I.D. Goldstrom, R.W. Manderscheid, and L.A. Rudolph, in their essay “Mental Health Services in State Adult Correctional Facilities,” Mental Health, United States (Washington D.C.: U.S. Government Printing Office, 1992).

324 In May 2000, a Prison Legal News investigative piece by Mark Sherwood and Bob Posey reported that 30 percent of Florida Department of Correction doctors have negative marks on their record.

325 Human Rights Watch telephone interview with Dr. Jeffrey Metzner, April 2, 2003.

326 Human Rights Watch telephone interview with Frederick Friedman, mental health director, Rhode Island Department of Corrections, April 2, 2003.

327 Human Rights Watch telephone interview with Harbans Deol, mental health director, Iowa Department of Corrections, April 2, 2003.

328 One of the clinician’s tasks was to screen inmates to make sure mentally ill prisoners had not been transferred to the MCF. His screening consisted of asking inmates a few questions at their cell door, e.g., whether they had thoughts of suicide. He did not review their medical and psychiatric records prior to meeting with them and did not do a formal mental status exam or a thorough psychiatric history with the inmates. Nor did he monitor the mental health of inmates on segregation, another one of his responsibilities. He acknowledged to Human Rights Watch that he rarely referred inmates to a psychiatrist. Human Rights Watch, Cold Storage: Super-Maximum Security Confinement in Indiana (New York: Human Rights Watch, 1997), pp. 75-77. Since the time of our research, Indiana has increased the mental health staff at MCF.

329 Human Rights Watch interview with Louis Mariani, chief psychologist, Graterford Prison, Pennsylvania, August 12, 2002. The numbers were provided by Mariani.

330 Human Rights Watch telephone interview with Linda Powell, director of utilization review and case management, University of Mississippi Medical Center, May 1, 2003.

331South Carolina Legislative Audit Council, A Review of Medical Services at the South Carolina Department of Corrections, March 2000. Report summary, p. 4. Available online at:, accessed on July 2, 2003.

332 Human Rights Watch telephone interview with Judy Stanley, director of accreditation, National Commission on Correctional Health Care, January 22, 2003.

333 Ruiz v. Johnson, 37 F. Supp. 2d 855 (S.D. Texas, 1999).

334 Ruiz v. Estelle, 503 F. Supp. at 1336.

335 See, e.g., Kenneth Appelbaum, et. al, Report on the Psychiatric Management of John Salvi in Massachusetts Department of Correction Facilities 1995-1996, submitted to the Massachusetts Department of Correction, January 31, 1997; on file at Human Rights Watch.

336 Human Rights Watch telephone interview with Tony Rome, clinical director, Bureau of Mental Health Services, February 10, 2003.

337 Human Rights Watch telephone interview with Roger Smith, director, Bureau of Mental Health Services, June 19, 2002.

338 Human Rights Watch telephone interview with Fred Cohen, December 12, 2002.

339 Wisconsin Legislative Audit Bureau, Prison Health Care, Department of Corrections: An Evaluation, May 2001.

340 Letter to Wyoming Governor James Geringer from Bill Lann Lee, acting assistant attorney general, June 29, 1999, available online at:, accessed on September 2, 2003.

341 Human Rights Watch interview with Doug Peterson, chief deputy clinical services and head of health care, California State Prison, Sacramento, California, July 18, 2002.

342 Human Rights Watch telephone interview with Hans Toch, November 22, 2002.

343 Human Rights Watch telephone interview with Fred Cohen, December 10, 2002.

344 Keith Curry, Ph.D. letter to the law offices of Donna Brorby, March 19, 2002, p. 28.

345 Goff v. Harper, Findings of Fact and Conclusions of Law, No. 4-90-CV-50365 (S.D. Iowa, June 5, 1997) (unpublished), p. 90.

346 American Psychiatric Association, Psychiatric Services in Jails and Prisons, 2nd Ed. (Washington D.C., American Psychiatric Association, 2000), p. 4.

347 Ibid.

348 Declaration of Kathryn A. Burns, M.D., M.P.H., November 6, 2002, Attached to Plaintiffs Motion for Preliminary Injunction, Fluellen v. Wetherington, Civil Case No. 1:02-CV-479-JEC (N.D. Georgia).

349 Patrick Sweeney, “State, Inmate’s Family Settle Suit,” Saint Paul Pioneer Press, April 23, 1996.

350 Jim Adams, “Report Raps Mental Health Treatment in State Prisons,” Star Tribune, April 29, 1995.

351 Patrick Sweeney, “State, Inmate’s Family Settle Suit,” Saint Paul Pioneer Press, April 23, 1996.

352 Letter to Wyoming Governor James Geringer from Bill Lann Lee, acting assistant attorney general, Civil Rights Division, U.S. Department of Justice, June 29, 1999.

353 Ibid.

354 Kathryn Burns, M.D. and Jane Haddad, Psy.D., “Mental Health Care in the Alabama Department of Corrections,” Bradley v. Hightower, Civ. No. 92-A-70-N (N.D. Ala., June 30, 2000) ), p. 66.

355 Human Rights Watch telephone interview with Linda Powell, May 1, 2003.

356 Written communication from Fred Cohen to Human Rights Watch, August 28, 2003.

357 Jeffrey Metzner, et al., “Treatment in Jails and Prisons” (1998), p. 220.

358 Terry Kupers, Prison Madness, 1999, p. 87.

359 National Commission on Correctional Health Care (NCCHC), Prison Health Care: Guidelines for the Management of an Adequate Delivery System (Chicago: NCCHC, December 3, 1990), p. 148 (quoting from correspondence from Walter Y. Quijano).

360 Dr. Metzner’s testimony is quoted by the court in Ruiz v. Johnson, 37 F. Supp. 2d 855, 902 (S.D. Texas, 1999)(internal citations omitted).

361 Ruiz, 37 F. Supp. 2d at 903 (internal citations omitted).

362 Ibid. (internal citations omitted).

363 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.

364 Correctional Association of New York, Mental Health in the House of Corrections, forthcoming report.

365 Fluellen v. Wetherington, First Amended Complaint, Civil Case No. 1:02-CV-479(JEC) (N.D. Georgia, March 15, 2002).

366 Human Rights Watch, Cold Storage: Super-Maximum Security Confinement in Indiana (New York: Human Rights Watch, 1997), p. 78. Dr. Terry Kupers visited facilities with Human Rights Watch and interviewed a number of seriously mentally ill prisoners.

367 Reickenbacker v. Foster, Complaint, Civil Action No. 99-910-C-1 (M.D. Louisiana).

368 Human Rights Watch telephone interview with Janet Schaeffer, psychologist and former director of mental health services, Washington Correctional Center for Women, April 29, 2003.

369 Jeffrey Metzner, et al., “Treatment in Jails and Prisons” (1998), p. 229.

370 Ibid.

371 Council of State Governments, Consensus Project (2002), p. 136.

372 Ruiz v. Estelle, 503 F. Supp. 1265, 1336 (S.D. Tex., 1980), aff’d in part, 679 F.2d 115 (5th Cir., 1982), cert. denied, 460 U.S. 1042 (1983).

373 American Psychiatric Association, Psychiatric Services in Jails and Prisons, 2nd Ed. (Washington D.C.: American Psychiatric Association, 2000), p.46.

374 Office of the Surgeon General of the United States of America, Mental Health: A Report of the Surgeon General, 2002, ch. 4.

375 Human Rights Watch telephone interview with Dr. Jeffrey Metzner, November 26, 2002.

376 Marnie Rice and Grant Harris, “The Treatment of Mentally Disordered Offenders,” Psychology, Public Policy and Law (March 1997), vol. 3, pp. 126-183.

377 Testimony of Dr. Terry Kupers, Jones ‘El v. Berge, Civil Case 00-C-0421-C (W.D. Wisconsin, 2001).

378 Human Rights Watch telephone interview with Dr. Jeffrey Metzner, February 12, 2003.

379 Declaration of Dr. Kathryn Burns, attached to Plaintiffs’ Motion for Preliminary Injunction, Fluellen v. Wetherington, Civil Case No. 1:02-CV-479-JEC (N.D. Georgia, February 20, 2003).

380 Kevin Corcoran, “Prison Mental Health Care: ‘Absolutely Atrocious,’” Indianapolis Times, September 17, 1997.

381 Final Report of the Special Master Mental Health, July 1999, p. 26, Duran v. Johnson, Civil Action No. 77-721-JC (N.M., 1999).

382 Ibid., p. 26, n. 20.

383 Human Rights Watch interviews, Graterford Prison’s Special Needs Unit, Pennsylvania, August 12, 2002.

384 The mental health staffing levels were provided by Linda Powell, director of utilization review and case management, University of Mississippi Medical Center, the organization contracted with the Department of Corrections to provide medical and mental health services in the state’s prisons. Human Rights Watch telephone interview with Linda Powell, May 1, 2003. The inmate numbers and size of the prison are numbers generated by the Mississippi Department of Corrections.

385 Human Rights Watch telephone interview with John Norton, associate professor of psychiatry and neurology, University of Mississippi, July 24, 2002.

386 Human Rights Watch telephone interview with Linda Powell, May 1, 2003.

387 Ibid.

388 BJS, Mental Health Treatment in State Prisons, 2000, 2001 appendix table B, p. 6.

389 Human Rights Watch visited Washington Correctional Center for Women, August 21, 2002.

390 Human Rights Watch telephone interview with Dr. Jeffrey Metzner, February 12, 2003.

391 The National Commission on Correctional Health Care, Accreditation Report, October 27, 2000, p. 6.

392 Russell v. Johnson, 2003 U.S. Dist. Lexis 8573 (N.D. Miss. May 21, 2003). Although the court was only addressing the conditions of death row inmates housed on Unit 32, experts for plaintiffs told Human Rights Watch that the conditions are the same throughout Unit 32, including appalling levels of mental health treatment.

393 Ibid.

394 Kathryn Burns, M.D. and Jane Haddad, Psy.D., “Mental Health Care in the Alabama Department of Corrections,” Bradley v. Hightower, Civ. No. 92-A-70-N (N.D. Ala., June 30, 2000) ), pp. 81-83.

395 Letter to Governor James Geringer from Bill Lann Lee, acting assistant attorney general, Civil Rights Division, U.S. Department of Justice, June 29, 1999.

396 Council of State Governments, Consensus Project (2002), p. 137.

397 This is similar to the Medicaid formulary, which gives mentally ill Medicaid patients access to the latest generation of anti-depressants and anti-psychotics.

398 Human Rights Watch telephone interview with Dr. Terry Kupers, February 7, 2003. In Mississippi, Kupers has found that the newer atypical medications are available, but only on a limited basis.

399 Human Rights Watch telephone interview with Patricia Perlmutter, attorney, May 13, 2002.

400 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. 62.

401 Email correspondence from Attorney Perlmutter to Human Rights Watch, July 15, 2003.

402 Letter from Dennis M. Jurczak, M.D. to Donna Brorby, Esq., re: Ruiz v. Scott, January 19, 1999, p.2; on file at Human Rights Watch. See also, letter from Dr. Jeffrey L. Metzner, to Donna Brorby, Esq. re: Texas Department of Criminal Justice, December 31, 1998, p. 10: “ Psychopharmacological treatment was problematic due to a formulary which did not include atypical antipsychotic medications and only one SSRI medication.” (referring to mental health treatment at the Estelle Unit prison complex).

403 Human Rights Watch Interview with Surya Edpuganti, staff psychiatrist, California Institute for Women, California, July 15, 2002.

404 Human Rights Watch interviews with mental health teams, California Institute for Women, California, July 15, 2002.

405 Human Rights Watch telephone interview with Todd Winstrom, attorney, Coalition for Advocacy, April 1, 2003.

406 Ibid.

407 Human Rights Watch telephone interview with John Norton, associate professor of psychiatry and neurology, University of Mississippi, July 24, 2002.

408 Kupers was contacted several times during the research for this report. This quote is from a telephone interview on October 10, 2002.

409 A Review of Medical Services at the SC Department of Corrections, Legislative Audit Council, March 2000, report summary, p. 4. Synopsis available online at:, accessed on September 8, 2003.

410 Human Rights Watch telephone interview with John Norton, M.D., July 24, 2002.

411 Human Rights Watch telephone interview with Todd Winstrom, attorney, Coalition for Advocacy, June 5, 2002.

412 Ibid., February 12, 2003.

413 Human Rights Watch interview with D.F., Corcoran, California, July 11, 2002.

414 Human Rights Watch interview with J.G., California State Prison, Sacramento, July 18, 2002.

415 Letter to Governor James Geringer from Bill Lann Lee, acting assistant attorney general, Civil Rights Division, U.S. Department of Justice, June 29, 1999.

416 Information on the side effects of these medications provided by Dr. Terry Kupers, Human Rights Watch telephone interview, October 10, 2002.

417 Ibid.

418 Kathryn Burns, M.D. and Jane Haddad, Psy.D., “Mental Health Care in the Alabama Department of Corrections,” Bradley v. Hightower, Civ. No. 92-A-70-N (N.D. Ala., June 30, 2000), p. 82.

419 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. 62.

420 Letter from Barbara C. Wolf, M.D. to Susan Werboff, director, Office of Protection and Advocacy for Persons with Disabilities, October 23, 2000; on file at Human Rights Watch.

421 Keith Curry, Ph.D. letter to the law offices of Donna Brorby, March 19, 2002, p. 20.

422 This is known as an anticholinergic effect, and is caused by the medications slowing the brain’s firing of the nerves that cause sweating, and by causing blood vessels in and under the skin to dilate, thus interfering with the body’s ability to cool itself through sweating and through peripheral vasodilation. They also suppress the center in the brain where temperature change is perceived and compensatory behavior initiated.

423 This quote was taken from the plaintiffs’ application for a temporary restraining order and/or preliminary injunction allowing plaintiffs’ counsel and experts to tour death row on August 8, 2002. Willie Russell v. Robert Johnson, 210 F. Supp. 2d 804 (N.D. Miss., 2002). Until the judge granted this order, Mississippi had refused to allow the ACLU or any of its medical experts into the prison to view conditions first-hand.

424 Dr. Vassallo, is a board-certified physician in Emergency Medicine and Medical Toxicology on the faculty of the New York School of Medicine/Bellevue Hospital Center. Susi Vassallo, M.D., “Report on the Risks of Heat-Related Illness and Access to Medical Care for Death Row Inmates Confined to Unit 32, Mississippi State Penitentiary, Parchman, Mississippi, for the National Prison Project of the American Civil Liberties Union, September 2002.

425 Russell v. Johnson, 2003 U.S. Dist. Lexis 8573 (N.D. Miss., May 21, 2003). The Department of Corrections sought a stay of the court’s order while it appealed the decision.

426 Human Rights Watch interview with D.O.F., California Institute for Women, California, July 15, 2002.

427 Human Rights Watch interview with E.F., California Institute for Women, California, July 15, 2002.

428 Laube v. Haley, Civil Action No. 02-T-957-N, Order (M.D. Ala., December 2, 2002), p. 23. Denying plaintiffs’ motion for a preliminary injunction, the court ruled that plaintiffs did not show a substantial likelihood of proving these conditions rose to a level of a constitutional violation, because of insufficient evidence in the record. It asked plaintiffs to provide more specific information on the temperature, humidity, and opportunities for inmates to gain relief from the heat.

429 Ibid.

430 Letter from Dr. Jeffrey L Metzner to attorney Donna Brorby, December 31, 1998 regarding the Texas Department of Criminal Justice.

431 Human Rights Watch telephone interview with David Lovell, professor, University of Washington, October 18, 2002.

432 Human Rights Watch telephone interview with Patricia Perlmutter, May 13, 2002. The settlement is reported at: D.M. v. Terhune, 67 F. Supp. 2d 401 (D.N.J, 1999).

433 Human Rights Watch telephone interview with Randall Berg, attorney, Miami, Florida, April 21, 2003.

434 Human Rights Watch interview with Marilyn Montenegro, social worker, Los Angeles, California, May 17, 2002.

435 Human Rights Watch interviews with Sue Burton, et. al., New Way of Life, a re-entry home in Watts, Los Angeles, California, May 17, 2002.

436 Information provided during Human Rights Watch telephone conference call with senior Washington Department of Corrections officials, February 28, 2003 and Human Rights Watch interview with Rich Jordan, community involvement officer, McNeil Island, Washington, August 22, 2002. McNeil Island’s mental health program is run as a pilot program, with the Washington Department of Corrections having contracted out much of the work to the University of Washington.

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October 2003