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I have been superintendent of the Bedford Hills Correctional Facility in New York State for 17 years. During that period of time, I have seen the number of mentally ill women entering the prison system rise precipitously. Where once mental institutions kept patients for long periods in back wards, today the burden of providing for mentally ill people who have committed crimes has shifted to the correctional system. It is clear that prisons must adapt by creating more appropriate environments for these inmates as long as society believes that is where mentally ill inmates should be maintained.”98

- Elaine Lord, superintendent, Bedford Hills Correctional Facility, New York

While serious mental illness is epidemic amongst both male and female prisoner populations, the statistics for female prisoners are particularly stark. A national study in 1999 by the Bureau of Justice Statistics based on a survey of prisoners, found that “[t]wenty nine percent of white females, 20 percent of black females and 22 percent of Hispanic females in State prison were identified as mentally ill. Nearly four in ten white female inmates aged twenty-four or younger were mentally ill.”99

Striking as they are, the Bureau of Justice Statistics (BJS) figures may not fully represent the extent of mental illness among incarcerated women. In New York, for example, 26 percent of incarcerated women are on the active mental health caseload (compared to 11 percent of men).100 In Pennsylvania, 37.7 percent of female prisoners are on that state’s mental health caseload.101 In the late 1990s, the Colorado Department of Corrections estimated that 27.9 percent of the women in the Colorado Women’s Correctional Facility had severe mental health needs.102 While women made up only 5.7 percent of the state’s total number of prisoners, they made up a startling 16.3 percent of the correctional system’s most seriously mentally ill prisoners.103 Georgia estimates that 33 percent of its female prisoners are mentally ill.104 In Vermont, of the forty-five prisoners at Dale Women’s Correctional Center, thirty-six were on the mental health roster as of September 2002.105 Arkansas’s deputy director of Health and Correctional Programs, Max Mobley, estimates twice as high a percentage of female prisoners are seriously mentally ill as are males.106 In Oregon, 47 to 49 percent of female prisoners are on the mental health caseload.107

Imprisonment may be even harder for women than for men. One crucial difference is that women prisoners are more likely to have dependent children who were living with them prior to incarceration.108 The separation from children because of incarceration — and particularly when, as if often the case, the prison is located far from the children — takes an enormous psychological toll on women. In addition to the grief, emptiness, anger, bitterness, guilt, and fear of loss or rejection that women prisoners who are mothers may experience, all women prisoners must cope with the stresses that are inherent in incarceration. Indeed, those stresses may be greater because facilities for women often lack the diversity and extent of educational, vocational, and other programs that are available (albeit typically in insufficient quantity and quality) in facilities for men.

Like men, women with mental illness can find themselves unable to adapt to and cope with prison life, with the result that they end up accumulating histories of disciplinary infractions. An analysis of data from the Bureau of Justice Statistics’ 1986 Survey of Inmates at State Correctional Facilities showed that women who currently or in the past had utilized mental health services had significantly greater disciplinary problems in prison; female prisoners currently on psychotropic medications had annual infraction rates that were twice that of other women prisoners — and, indeed, had higher infraction rates on average than male prisoners who were also on medication.109 As Superintendent Elaine Lord has written, mental illness “impacts [women’s] performance and even her participation in programs… [it affects their] ability to abide by the rules and routine of an institution that is styled on military protocols for following orders and establishing routines”110 At Bedford Hills Correctional Facility, a New York prison for women, 80 percent of the “Unusual Incident Reports” (staff documentation of incidents involving serious threat to facility safety or security) involved prisoners who were on the active mental health caseload. Although women prisoners are typically less violent than men — and mentally ill women less violent than mentally ill men — they can and do cause injuries to themselves and others. Superintendent Lord observes:

Obviously, one of the dangers of having seriously mentally ill women in prison is that they are a source of violent acts within the inmate community that are very difficult to prevent because they are tied to mental illness; they simply make no sense. Just as the public has difficulty comprehending why a mentally ill person pushes someone off a train platform, so, too, prisoners and correction staff have difficulty comprehending seemingly random acts of violence perpetrated within a prison.111

Although the rate at which women are incarcerated has soared in the past decade, in great part because of the war on drugs, they still represent a small segment of the prison population.112 Most prison systems still have not developed adequate facilities for women at different security levels and do not offer women prisoners the range of programming and services that are available to men. Prison medical care for women is particularly deficient, including mental health care.

In New York State, women who are seriously mentally ill must be confined at Bedford Hills Correctional Facility, a maximum-security prison, even if their security level is minimum or medium, because it is the only prison for women in the state with intensive mental health services. Over half of the population at Bedford Hills is on the active mental health caseload; and half of those cases fall within the two highest need categories for mental health services. Twenty-two percent of the prisoners on the mental health caseload were diagnosed with schizophrenia, 21 percent with depressive disorders, and an additional 13 percent were diagnosed as psychotic, not otherwise specified.113

In 1997, researchers from Northwestern University’s Psycho-Legal Studies Program investigating jail conditions found that “because there are relatively few female inmates, the per capita cost is too high to provide them with comparable services” to the specialized mental health treatment available in an increasing number of male institutions.114 Focusing on a random sample of 1,272 female arrestees, the researchers found that “less than one quarter of female jail detainees who had severe mental disorders and needed services received them while they were in jail.”115 The lack of services affects not only women in jail pending trial or serving short jail sentences, but also women serving longer prison sentences in the six states which house prison and jail inmates in the same facilities.116

In Vermont, the Chittendon Community Correctional Center is the intake jail in Burlington that deals with 40 percent of all intakes in the state. In the fall of 2002, between eighty and ninety women were there on any given day out of a total population of 197 prisoners.117 Based on the numbers diagnosed with serious mental illness, jail Superintendent Susan Blair believes that the female prisoners should be assigned three to four times the number of hours of mental health services provided to male prisoners; yet, because of scarce resources, they end up being provided with only double the amount allocated the men.118 “The women are a much needier group,” Blair told Human Rights Watch. “It’s more challenging for the staff here to deal with some of these folks.”

Even in states which make an effort to provide adequate mental health services for their prisoners, women are often short-changed. For example,U.C., a one-time prisoner in Pennsylvania’s prison system, told Human Rights Watch that in Muncie women’s prison, Pennsylvania, there was:

very little mental health care. I was devastated. I hated it there. I saw the psychiatrist every three months and a counselor once in a while. There was nobody to talk to. They told me to go to church — that that would help me…. I remember trying so hard to remain in contact with reality before they put me back on Haldol. It took a week to see the psychiatrist and get put back on Haldol. They said “you’ll just have to wait till he gets around to you.”

After Muncie, U.C. was moved to Cambridge Springs Prison.

I still had to wait four or five days to see the psychiatrist if I needed anything. I was doing good the first four years. Then I became incoherent again. They had me in a padded cell about a week. Then I improved. They put me on more medicine. I’ve been doing good since.119

Wisconsin Coalition for Advocacy attorney Todd Winstrom, who has represented mentally ill clients at Taycheedah women’s prison, told Human Rights Watch that there are lower mental health staffing levels at Taycheedah than in men’s prisons in the state and there is less access to drug and alcohol programming. Although men’s prisons have had specialized mental health units for several years, Taycheedah only opened its mental health unit in 2001.120

In 1993, prisoners at the Washington Corrections Center for Women (WCCW), brought a class action lawsuit, Hallett v. Payne, challenging the quality of medical,dental and mental health services at the facility. Under a 1995 consent decree, prison administrators agreed to develop a comprehensive plan to significantly upgrade delivery of medical, dental, and mental health care services to meet minimal constitutional standards.121 The court in Hallett mandated an unspecified “adequate staffing” level, to be determined by an independent monitor; upgrades in the prison’s information management system; the creation of a more streamlined method for delivering medications; and the presence of mental health staff available for evaluation and treatment five days per week.122

In 1999, hearings were held to determine whether federal court jurisdiction over mental health services at WCCW should continue.123 The plaintiffs presented evidence that the facility continued to lack enough mental health staff to meet the serious mental health needs of the prison population; that programming and treatment remained unduly limited and inconsistent; that prisoners were given disciplinary tickets for self-harm behavior even if it was a result of mental illness; that mentally ill prisoners were inappropriately placed in segregation unit to control their behavior and that prisoners in need of intensive psychiatric care were kept at WCCW even though it could not provide the services necessary for them. While the court concluded it had concerns about the staffing and state of mental health services, it was persuaded that substantial efforts had been made to improve the delivery of mental health care at WCCW and that overall care did not fall below constitutional standards. It therefore ruled that the prospective-relief provisions of the Prison Litigation Reform Act barred it from granting plaintiffs’ motion to extend the court’s jurisdiction. In its decision, it pointed out that most of “the medical experts and staff expressed the opinion that WCCW was ‘coping’ with its mental health issues, but that its resources for delivering care were operating at full capacity, with little or no margin for planning, innovation , or increasing care for individual inmates.” 124

When Human Rights Watch visited WCCW in August 2002, it was in the process of expanding the number of full-time psychologists from five to eight. It had also hired arisk management specialist.125 Superintendent Stewart was committed to boosting mental health services to the maximum extent possible within budget constraints. “Uncontrolled, it [mental illness] would wreak absolute havoc on this institution,” she explained. “As sick as some of the women are. I’d like to see the ability to do better transitioning. When inmates leave here, all our great work goes to hell if they go out and there’s no support for them. I’d also like better training for staff. What we have now is decent, but we need to do more — or else we can become part of the problem.”126

Case Study: R.M. and Seriously Mentally Ill Women Prisoners in Vermont

Because Vermont’s prison system is so small, the state has not built a specialized mental health unit for its women prisoners. Prisoners and outside observers acknowledge that the mental health services provided at the Dale Women’s Facility are excellent. But if women become unmanageable at Dale (which is an open-plan prison in which prisoners are free to wander the facility and intermingle during the day) they are transferred to the administrative segregation unit at the Chittendon Community Correctional Center in Burlington, Vermont, which is also operated by the state Department of Corrections.127 While most of the Chittendon Community Correctional Center’s prisoners are either pre-trial or serving time for misdemeanor convictions, the facility thus also holds women serving longer prison sentences. Chittendon’s mental health staff, however, is limited to a part-time psychiatrist and two counselors. Prisoners with mental health needs have no access to group therapy, infrequent access to counselors, and many report they are routinely provided ample opportunity to self-mutilate. “We need to have a mental health unit,” Chittendon Superintendent Susan Blair stated. “We might get services — a full-time clinician who would give more attention to the folks.”128 In addition, because the correctional center was not built to deal with seriously mentally ill prisoners, it does not have any specially designed observation cells for female prisoners in need of around-the-clock constant observation. Thus, when a prisoner gets to the point where they need non-stop observation, they have to be placed in the grimy holding cells that are usually reserved for those brought into the jail for the night to sleep off drinking binges.129

R.M. was twenty years old when Human Rights Watch interviewed her at Chittendon where she was being held in an administrative segregation cell. Inside the facility, R.M., who is a heroin addict and who was severely sexually abused as a child, hurts herself on a regular basis. Her arms are criss-crossed with raw, red cuts. One of her legs, on the day Human Rights Watch met her, had a big, bloody, open wound. R.M. stated that she jabs pencils into her limbs, that she cuts herself with razors, and that she sticks staples, retrieved from the bindings of magazines, into her open wounds. She also smashes her head against the walls of her cell when she gets agitated. Ill with serious diabetes, R.M. confided her desire to kill herself by depriving herself of needed diabetes medications. “I’m going to kill myself here and they don’t care,” she told Human Rights Watch. “I know how to do it. I can. I swallowed a pencil the other day. That was fun. I shove things in my legs all the time and they don’t care.” R.M. expressed a desire to return to the state mental hospital. “I wish I could,” she says, pouting like a child. “They don’t have enough staff. It’s ok. If they don’t take me, I’m going to kill myself.”130

Although the mental health staff do not think that R.M. has an axis-1 disorder, they do believe she has one of the most severe cases of borderline personality disorder they have ever seen; they believe she will never be able to function normally in a prison’s general population, or, for that matter, out in the community.131 The mental health evaluation notes for R.M. list a “long hx [history] of severe behavioral disturbance, borderline personality, PTSD, Hx of drug abuse, diabetes.” It also records that she has a history of being seriously abused. Over the period of her involvement with mental health services at Chittendon, she has been listed as being agitated, angry, irritable, depressed, and as needing anti-depressant medication, mood stabilizers, and antipsychotics.

R.M.’s story is not one that revolves around indifferent correctional staff. The staff at Chittendon, and, indeed, the mental health teams throughout the state’s prison system, devote weekly meetings to R.M.’s case. But the Vermont prison system lacks the resources to provide adequate services to seriously mentally ill individuals, particularly those like R.M. who belong in a hospital. Faced with the behavioral outbursts of R.M., security staff have believed they have no alternative but to isolate her from other prisoners and keep her locked in her cell twenty-three hours a day. In a period of under a year, R.M. has picked up nearly fifty disciplinary reports, for offenses including the use of obscene language, flooding her cell, defacing state property, and assault.132 She has been placed on suicide watch periodically and is routinely written up for acts of self-harm.

The mental health team at Chittendon informed Human Rights Watch that despite repeated requests to the state mental hospital to take R.M. in, and despite the hospital’s promises that it would develop a plan on how to admit and treat her, it has continuously dragged its feet. The team suspects the hospital’s reluctance to admit R.M. may be connected to the fact that when R.M. was previously at the hospital she threatened to stab her psychiatrist. When interviewed, R.M. was serving six-to-eighteen months on charges of possession of heroin, unlawful mischief, and disorderly conduct. Because the hospital was taking so long to develop a plan for her, it is likely that her sentence would be up before she was ever removed into a hospital setting. A typical memo written by mental health staff following one of the weekly team meetings reads as follows:

[A staff member from the Vermont State Hospital] updated the team that they are short on staffing resources and there were some directive issues that Dr. F. wanted resolved prior to R.M. going to VSH [Vermont State Hospital.] She was unable to give any time line as to when these pieces would be resolved. There is vagueness in what exactly needs to be put in place to receive R.M.…. R.M. appears to be regressing through this process and is convinced that VSH is playing games so as not to take her. She believes they do not want her.133

It is, as the staff freely admit, a far from happy situation. The Vermont prison system’s chief psychiatrist, Dr. Michael Upton, told Human Rights Watch that “this is not therapy. This is management. It’s trying to keep the symptoms few.”

Human Rights Watch also interviewed mentally ill women at the Dale prison who had also spent time at Chittendon. One prisoner, J.F.D. has bounced back and forth between Dale prison and Chittendon jail for three years. Describing conditions at the jail she said “I’d put a slip in on Sunday night for suicidal thoughts. They’d get it Monday and it’d be three weeks before they see you.” Inside the jail, this prisoner slit her wrists several times, slammed sharpened pencils into her arms, and even carved her son’s initials into her left arm. “They’d just look at you like ‘that’s dumb,’ and not give you any mental health counseling,” she recalled.134 Another Dale prisoner, V.O., stated that she was at the jail for five and a half months. “You don’t get to see your caseworkers. The doctor only comes in once a week. Sometimes they put you on the wrong medications.”135 A third, Q.F., stated that access to mental health at the jail “was hit or miss. I never knew when I was going to see my mental health counselor.” All of these women said that at Dale prison, unlike at Chittendon, the mental health services were superb and the staff extremely respectful. It appeared, therefore, unlikely that these women were simply malcontents.136

98 Elaine Lord, “Prison Careers of Mentally Ill Women,” in Hans Toch and Kenneth Adams, Acting Out, 2002, p. 368.

99 BJS, Mental Health and Treatment of Inmates and Probationers, 1999, p. 3.

100 Figures as of 2000, from Lord, “Prison Careers of Mentally Ill Women,” p. 369.

101 Human Rights Watch interview with Lance Couturier, Ph.D., mental health director, Pennsylvania Department of Corrections and Fred Maue, Ph.D., chief of clinical services, Pennsylvania Department of Corrections, Gaudenzia House, Philadelphia, August 13, 2002.

102 Colorado Department of Corrections, Adult Inmate Profile. Numbers accurate as of June 30, 1998.

103 Ibid.

104 Figure provided by Michael Hitchcock, Program Development Division, Georgia Department of Corrections, in response to Human Rights Watch survey, June 24, 2002.

105 Human Rights Watch interviews, Dale Women’s Correctional Center, Vermont, September 26, 2002. Information on the mental health roster was provided by the chief psychiatrist for the Vermont Department of Corrections, and by Matrix, the mental health care provider with whom the Vermont Department of Corrections contracts for services.

106 Written communication to Human Rights Watch from Max Mobley, director of mental health, Arkansas Department of Corrections.

107 Human Rights Watch telephone interview with Gary Field, administrator for counseling and treatment services, Oregon Department of Correction, June 24, 2002. Oregon DOC also provided written answers to a Human Rights Watch survey.

108 Christopher J. Mumola, Incarcerated Parents and Their Children, Bureau of Justice Statistics, August 2000, table. 4: 64.3 percent of state female parents and 84 percent of federal female parents lived with their children prior to incarceration, compared to 45.3 percent of state male prisoners and 55.2 percent of federal male prisoners. Available online at:, accessed on August 26, 2003.

109 Richard C. McCorkle, ”Gender, Psychopathology, and institutional Behavior: A Comparison of male and Female Mentally Ill Prison Inmates,” Journal of Criminal Justice, vol. 23, no. 1, 1995, pp. 53-61.

110 Lord, “Prison Careers of Mentally Ill Women,” p. 375.

111 Ibid., p. 381

112 According to the Bureau of Justice Statistics, at the end of 2002, women made up 6.8 percent of the state and federal prison population. BJS, Prisoners in 2002, p. 1.

113 Lord, “Prison Careers of Mentally Ill Women,” p. 374.

114 Linda Teplin, Karen Abram, and Gary McClelland, “Mentally Disordered Women in Jail: Who Receives Services?” American Journal of Public Health, vol. 87, no. 4, April 1997. As a further reference on this subject, the authors footnote a book by C. Feinman, Women in the Criminal Justice System (Westport, Conn., 1993).

115 Ibid., p. 607.

116 BJS, Prisoners in 2002, p. 11

117 Human Rights Watch visited Chittendon Jail, Burlington, Vermont, September 26, 2002. Intake numbers provided by Superintendent Susan Blair.

118 Human Rights Watch interview with Susan Blair, superintendent, Chittendon Community Correctional Center, Burlington, Vermont, September 26, 2002.

119 Human Rights Watch interview with U.C., Philadelphia, Pennsylvania, August 13, 2002.

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

121 ACLU of Washington Annual Report 1999-2000, Available online at:, accessed on September 8, 2003.

122 Human Rights Watch telephone interview with David Fathi, Esq., ACLU National Prison Project, April 2, 2003.

123 Under the terms of the agreed order settling the case, federal court jurisdiction would expire in four years unless extended upon a showing of defendants’ non-compliance. The prisoners moved to extend jurisdiction; the defendants moved to vacate the judgment under the Prison Litigation Reform Act.

124 Report and Recommendation, Hallett v. Payne, Case No. C93-5496FDB, September 3, 1999. The court’s findings with regard to mental health services were affirmed on appeal. Hallett v. Morgan, 296 F.3d 732 (9th Cir., 2002).

125 Human Rights Watch visit August 21, 2002. Information on the mental health system and employee numbers was provided by Superintendent Belinda Stewart and program clinical manager Dr. Rob Newell.

126 Human Rights Watch interview with Superintendent Belinda Stewart, August 21, 2002.

127 Dale prison for women holds approximately forty-five inmates, and has no separate, secure area for inmates who are acting out so violently that they cannot be around other inmates.

128 Human Rights Watch interview with Susan Blair, superintendent, Chittendon Community Correctional Center, Burlington, Vermont, September 26, 2002.

129 Human Rights Watch was shown these holding cells during our September 26, 2002 visit.

130 Human Rights Watch interview with R.M., Chittendon Community Correctional Center, Burlington, Vermont, September 26, 2002. At the time, R.M. was scrubbing her walls clean of the graffiti she’d spent the previous days covering her cell with.

131 Human Rights Watch interviewed mental health team at Chittendon Jail, Burlington, Vermont; and John Holt, mental health director, Matrix Health Systems, Northwest State Correctional Facility, Vermont, September 26, 2002.

132 Human Rights Watch obtained a copy of R.M.’s disciplinary report from the Vermont Department of Corrections; on file at Human Rights Watch.

133 This memo is contained in R.M.’s mental health files, obtained by Human Rights Watch after receiving a signed release from R.M. This particular memo refers to a meeting held September 17, 2002.

134 Human Rights Watch interview with J.F.D., Dale Women’s Facility, Vermont, September 26, 2002.

135 Human Rights Watch interview with V.O., Dale Women’s Facility, Vermont, September 26, 2002.

136 Human Rights Watch interview with Q.F., Dale Women’s Facility, Vermont, September 26, 2002.

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October 2003