Not only is the number of prisoners with mental illness growing, but more persons are being incarcerated whose illnesses fall at the most severe end of the mental illness spectrum. According to Dave Munson, lead psychologist at Washington State’s McNeil Island Correctional Center, “the severity of the mental illness of those coming in is increasing. People are no longer going to state hospitals. The prisoners often have no idea how they ended up here.”72 In Oregon, the administrator for counseling and treatment services reported that in the last five years the prison system has begun receiving prisoners who have been in mental health group homes since childhood.73 Gloria Henry, warden of Valley State Prison for Women, California’s largest prison for female prisoners, also points to the severity of the mental conditions of incarcerated women:
Mental disorders include a broad range of impairments of thought, mood, and behavior. The degree of impairment can vary dramatically from individual to individual. Also, some individuals with mental illness have periods of relative stability during which symptoms are minimal, interspersed with incidents of psychiatric crisis. Other individuals are acutely ill and dramatically symptomatic for prolonged periods.
In this report, we use the term serious mental illness to refer to diagnosable mental, behavioral, or emotional disorders of sufficient duration to meet diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, (generally referred to as DSM-IV)75 and that result in substantial interference with or limitations on one or more major life activities.76 The DSM-IV defines a mental disorder as:
The DSM-IV classification for mental disorders includes serious mental illness (Axis 1) and serious personality disorders (Axis 2). In prisons, the category of serious mental illness is typically limited to such conditions as schizophrenia, serious depression, and bipolar disorder. Schizophrenia is a frightening, complex, difficult, and debilitating disease which may include disordered thinking or speech, delusions (fixed, rigid beliefs that have no basis in reality), hallucinations (hearing or seeing things that are not real), inappropriate emotions, confusion, withdrawal, and inattention to any personal grooming. Among the subtypes of schizophrenia is “paranoid schizophrenia” with characteristics of delusions of persecution and extreme suspiciousness. Even if a person with schizophrenia is described as recovered or in remission, quite likely he or she is neither ill nor well, but will usually have a great deal of difficulty adjusting to life situations, and can be driven over the edge by overwhelming demands.78 Serious or clinical depression, which can be experienced episodically or chronically, usually includes, among other symptoms, profound feelings of sadness, helplessness, and hopelessness. It can also be accompanied by psychotic features, including hallucinations and/or delusions. Clinical depression, which is far more common among women than men, is a significant suicide risk factor. Bipolar disorder (previously called manic-depressive disorder) is characterized by frequently dramatic mood swings from depressions to mania. During manic phases some people may be psychotic and may experience delusions or hallucinations.
Wholly apart from ensuring adequate mental health treatment, the incarceration of thousands of persons with these illnesses poses extremely difficult management challenges for correctional staff trying to ensure prison safety and security. For example, serious depression puts people at risk of suicide. Persons with schizophrenia may experience prison as a peculiarly frightening, threatening environment that can result in inappropriate behavior including self-harm or violence directed toward staff or other prisoners. Persons with bipolar disorder in a manic phase can be disruptive, quick to anger, provocative, and dangerous.79 Prisoners with serious mental illness, particularly if the illness has psychotic features, may find it next-to-impossible to abide by, or, in more extreme cases, even to understand, prison regulations. According to correctional mental health expert and clinical professor of psychiatry at the University of Colorado’s Health Sciences Center Dr. Jeffrey Metzner, “A small percentage [of prisoners] don’t understand the rules. They’re the ones who are psychotic. More common is that prison rules don’t mean much to someone hearing voices — that’s the least of their problems.” A person with paranoid schizophrenia, said Metzner, may, on a literal level, understand a rule but nevertheless view a request to abide by that rule as being part of a conspiracy directed against him. “It’s less of not understanding and more of acting on distortions.”80
It is not uncommon for persons who end up in jail or prison to have Axis 2 personality disorders which result in serious problems in thinking, feeling, interpersonal relations, and impulse control. When these disorders are associated with significant functional impairments they constitute serious mental illnesses. According to the DSM-IV, personality disorders are “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”81
Perhaps the most prevalent personality disorders among jail and prison inmates are anti-social personality disorder (ASPD) and borderline personality disorder. The essential feature of the former is “a pervasive pattern of disregard for, and violation of, the rights of others.”82 Persons with antisocial personality disorder, typically men, can be particularly difficult to manage in a correctional setting. They can often be manipulative, volatile, disruptive, and likely to engage in aggressive, impulsive “acting out” behavior which can include assaults on others, self-mutilation and/or suicide attempts. Epidemiological research shows that only 15 percent to 20 percent of prisoners have bona fide ASPD, if the diagnosis is made using the criteria in the DSM-IV. Yet, according to psychiatrist Dr. Terry Kupers, who has examined mental health services in many prisons, correctional mental health staff have a tendency to over-diagnose the presence of ASPD, essentially using it as a default diagnosis for anyone who seems to have mental problems of some sort but does not have an obvious Axis I illness. A diagnosis of ASPD becomes, in fact, a moral rather than clinical judgment; prisoners with APSD are “bad” not “mad.”83
According to the DSM-IV, borderline personality disorder is marked by “patterns of instability in interpersonal relationships, self-image and affects, and marked impulsivity that begins in early adulthood.” People with borderline personality disorder often have volatile and extreme emotions, are prone to depression, and can be difficult and manipulative. Many resort to self-mutilation at some point. Borderline personality disorder can also include episodes of psychotic decompensation. Research suggests that childhood trauma — particularly sexual and physical abuse — is one of the causal factors for the disorder. About 70 to 77 percent of people diagnosed with this disorder are women.84 Some psychiatrists, such as Harvard University’s Dr. Judith Herman, believe that many, if not most, women diagnosed as borderline are in fact suffering from what Herman calls, “complex posttraumatic stress disorder.” The multiple traumas cause psychological disorganization and emotional dyscontrol that look very much like borderline personality disorder. If the diagnosis, however, is of borderline personality disorder, the complex posttraumatic stress disorder is ignored and, all too often, the women are considered just plain difficult and not amenable to or in need of treatment.85
Although people with personality disorders may appear “normal” — just obnoxious or difficult — these mental disorders are very real and drive those who have them to behave the way they do. Unlike Axis 1 mental illnesses, personality disorders are not believed to be caused by abnormality of brain chemistry or other organic problems, but are rooted in life histories, such as childhood traumas and neglect, and perhaps genetics. For that reason, they do not generally respond to medications and are thus harder to treat and contain. Personality disorders can and often do co-exist with Axis-1 mental illnesses, further complicating the diagnosis and treatment of both.
It is a convention in correctional psychiatry to identify as serious mental illnesses only certain serious Axis I disorders such as bipolar disorder, major depression, and schizophrenia, and to limit mental health treatment to prisoners with those disorders. It is a convention in part created by the shortage of mental health staff: absent sufficient numbers to treat everyone, the determination of who warrants treatment is restricted to the most deeply troubled individuals and also those who are more likely to respond to the primary treatment modality offered in prison — medication. Correctional mental health staff are particularly reluctant to expend treatment time on prisoners with personality disorders. The judgment of correctional mental health staff about the seriousness of a non-psychotic mental condition may also be colored by their concerns that prisoners may be malingering or seeking secondary gains. It is also a convention that survives under constitutional jurisprudence that has failed to clarify the boundaries of the “serious mental illness” for which mental health services are required.
Nevertheless, individuals who suffer from other illnesses not on the short list of Axis I disorders can be equally distressed and disabled. Some personality disorders can include episodes of psychotic decompensation and several of the personality disorders can result in severe disability. For example, an individual suffering from a severe generalized anxiety disorder with panic attacks might spend all of her time terrified, incapable of acting productively, and cringing in her cell. Someone with severe obsessive-compulsive disorder might spend all his time cleaning his cell or counting cracks in the wall and be completely incapable of undertaking other activities. A person with a dysthymic disorder (a less severe form of depression than a major depressive disorder) might successfully commit suicide.
Failure to diagnose and properly attend to prisoners’ personality disorders can lead to inappropriate responses by correctional staff that aggravate the prisoners’ conduct and heighten the incidence of self-mutilation and suicide attempts. The clinical diagnosis of personality disorders should be followed with useful therapeutic interventions, such as individual and group talk therapy and cognitive skills and anger management training. Medication cannot address the fundamentals of personality disorders but can alleviate frequently concomitant symptoms, such as depression and anxiety. Mental health interventions can not only make life in prison more tolerable both for the prisoners and the staff who have to deal with them; they also can provide the prisoners with life-skills — such as personal hygiene, education, anger management, and an ability to recognize the signs of an approaching mental health crisis — that will serve them well when they are released from prison.
To provide a sense of the nature and degree of serious mental illness from which some prisoners suffer, we note below some descriptions, many of which were made by mental health experts and courts who had access to complete mental health records:
71 Human Rights Watch interview with D.O.T., California State Prison, Corcoran, Enhanced Outpatient Program, California, July 11, 2002.
72 Human Rights Watch interview with Dave Munson, head psychologist, McNeil Island Correctional Center, Washington, August 22, 2002.
73 Human Rights Watch telephone interview with Gary Field, administrator for counseling and treatment services, Oregon Department of Corrections, June 24, 2002.
74 Human Rights Watch interview with Gloria Henry, warden, Valley State Prison for Women, California, July 17, 2002.
75 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington D.C.: American Psychiatric Association, 1994).
76 This is the definition used by The President’s New Freedom Commission on Mental Health, “Achieving Promise: Transforming Mental Health Care in America,” p. 2 (July 23, 2003), available on line at: http://www.mentalhealthcommission.gov/reports/FinalReport/toc.html, accessed on August 26, 2003.
77 Ibid., xxi-xxii.
78 Hans Toch and Kenneth Adams, Acting Out: Maladaptive Behavior in Confinement (Washington D.C.: American Psychological Association, April 2002), p. 16
79 See Martin Drapkin, Management and Supervision of Jail Inmates With Mental Disorders (New Jersey, Civic Research Institute, 2003), ch. 4, which provides an excellent overview of the nature of and correctional implications of various mental diseases and disorders.
80 Human Rights Watch telephone interview with Dr. Jeffrey Metzner, clinical professor of psychiatry, University of Colorado Health Sciences Center, April 2, 2003. Dr. Metzner is a nationally recognized psychiatrist and correctional mental health expert who has provided evidence on prison mental health conditions in dozens of cases.
81 Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington D.C.: American Psychiatric Association, 1994), p. 629.
82 Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington D.C.: American Psychiatric Association, 1994).
83 Email communication from Dr. Terry Kupers to Human Rights Watch, May 29, 2003.
84 Sartx, Blazer, George & Winfield, “Estimating the Prevalence of Borderline Personality in the Community,” Journal of Personality Disorders, vol. 4, no. 3 (1990), pp. 257-272; Nehls, “Borderline Personality Disorder: Gender Stereotypes, Stigma, and Limited System of Care,” Issues in Mental health Nursing, vol. 19 (1998), pp. 97-112. Some mental health professionals believe the diagnosis of borderline personality disorder has become a demeaning “wastebasket” category into which difficult women are lumped. Email communication from Dr. Terry Kupers to Human Rights Watch, May 20, 2003.
85 Email communication from Dr. Terry Kupers to Human Rights Watch, May 20, 2003. See also, Judith Herman, M.D., Trauma and Recovery (New York: Basic Books, 1997).
86 Jones ‘El v. Berge, 164 F. Supp.2d 1096, 1108 (W.D. Wis., 2001).
87 Ruiz v. Johnson, 37 F. Supp. 2d 855, 909 (S.D. Tex., 1999).
88 Letter from Keith Curry, Ph.D. to attorney Donna Brorby, March 19, 2002, pp. 19-20; on file at Human Rights Watch. Brorby was the lead attorney in Ruiz v. Johnson, a lawsuit over Texas prison conditions, and Curry visited the prisons on behalf of the plaintiffs.
89 New Jersey Prison System Report of Dr. Dennis Koson, C.F. v. Terhune, Civil Action No. 96-1840 (D.N.J., September 8, 1998), on file at Human Rights Watch. The trial court approved the parties’ settlement of the case on July 30, 1999. D.M. v. Terhune, 67 F. Supp. 2d 401 (D.N.J., 1999).
90 Mental health evaluation of V.Y.A. by Illinois Department of Corrections, December 31, 1998; on file at Human Rights Watch.
91 Human Rights Watch, Cold Storage: Super-Maximum Security Confinement in Indiana (New York: Human Rights Watch, 1997), pp. 36-37. The prisoner was examined by psychiatrist Terry Kupers, who served as a consultant to Human Rights Watch.
92 Ibid., p.37. Psychiatrist Terry Kupers also examined this prisoner.
93 Dr. Stuart Grassian, Second Site Visit to the Attica SHU, Mental Health Care, Eng v. Goord, Civ 80-385S (W.D. New York, October 1999) (redacted copy). In his report, Dr. Grassian provides detailed descriptions of the conditions, behavior and medical history of eight seriously mentally ill inmates incarcerated in the secured housing unit at Attica. His report also documents in detail the failure of the mental health staff to provide proper treatment for these inmates and the deterioration of their conditions accompanying prolonged incarceration in segregation. Dr. Stuart Grassian, Second Site Visit to the Attica SHU, Mental Health Care, Eng v. Goord, Civ 80-385S (W.D. New York, October 1999) (redacted copy), p. 40.
94 Mental Status Evaluation of an inmate [name withheld] by Katherine Burns, M.D. dated April 3, 1999; on file at Human Rights Watch.
95 Human Rights Watch telephone interview with Jennifer Givens, attorney, Virginia Capital Representation Resource Center, October 2, 2002.
97 Human Rights Watch interview with V.P., Corcoran, California, July 11, 2002.