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Prison or Mental Hospital? The Debate Continues

Article by Kristin Martin

Mental health is widely acknowledged as a controversial issue in the United States incarceration system. A 2005 study by the Bureau of Justice Statistics (BJS) reported that 56 percent of state prison inmates have mental health problems. More recently, NPR reported that 350,000 imprisoned offenders had a mental illness in 2011.

Meredith Allison, an associate professor of psychology at Elon University, said there are a couple factors to this statistic. The first is situational, she said.

"Being in prison can bring on mental illness," Allison said. "So some of the individuals in prison might be dealing with depression or anxiety at the beginning of their sentence because of the transition from autonomy and being out in the real world to a highly regimented environment in prison. And then that stress tends to ease off over the sentence but then re-emerges close to release."

And then there are the offenders that already have a mental illness and are imprisoned.

"Just by getting large numbers of people together you’re going to get people with mental illness, but it’s disproportionally seen in the offender population," Allison said. "Some research suggests that is related to the discharge of people from psychiatric wards, so you get a lot of individuals who are institutionalized, then released and are now in the community and are more susceptible to being questioned by police because they’re disruptive and are re-imprisoned again."

Video by Christine Williams.

The most relevant mental illnesses include depression and substance abuse. Allison said anxiety is also frequently an issue since it is closely related to depression.

"Prevalence rates are going to be substance use abuse — alcohol dependence, alcohol abuse, marijuana, cocaine," said L. Alvin Malesky, Jr., Ph.D., an associate psychology professor at Western Carolina University with a history as a psychologist with a prison treatment program. "From there, you’re dealing with everything: personality disorders, to serious mental illness, schizophrenia, things of that nature. The people that I see in my forensic role are typically those with serious mental illness, those with schizophrenia, those with bipolar disorder, thought disorders, mood disorders."

Schizophrenia is often talked about as prevalent in prisons, but in reality it's a much smaller subset of the general population, so it's less likely than depression, said Allison.

"Related to depression and anxiety is suicide," Allison said. "So there's the suicide watch, you kind of hear about that in prison. That’s a related concern, but other than that, it’s depression.

It is more likely for a state prison inmate to have a mental illness if he has a substance dependency or abuse problem or had parents who abused alcohol or drugs.

The BJS study reported 22.3 percent of state prison inmates received mental health treatment during the year before arrest, but 33.8 percent received treatment after admission. Most of these treatments are through prescribed medications.

"People have felt that [mental health statistics increase] as a result of being in jail, but I think there are other causes that go further in explaining higher prevalence rates," Malesky said.

Treatment in Prisons

When it comes to treating inmates with mental health problems, the quality of the program varies from from prison to prison.

Malesky said a small local jail isn't likely to have the proper resources to provide extensive care, while a larger facility might have a psychologist or psychiatrist that can work with the inmates.

"As far as treatment goes, a big treatment is pharmacological intervention," he said. "That is medication, antidepressants, anti-anxiety meds, antipsychotics, food stabilizer medications in that regard.  Also, we seek group and psycho-educational treatments."

Allison said inmates usually have a psychological screening when brought into prison.

"They should get a psychological screen so that would be, if not a licensed Ph.D. level psychologist then someone with a master's, someone with some kind of training in mental health," she said. "They’re just looking for indicators, so suicide, depression, anxiety, substance use, and then referring that person on for help."

Whether or not the inmate chooses to take it or not is a different issue. Allison said some offenders may not want to down to the mental health unit, but some are relieved to get away from the general population and see a doctor. Therapy isn't even always guaranteed to help, but for some, it's the only way to have that option.

"For some individuals, this is their only chance to get access to services," Allison said. "So the problem is not are they getting it in there, but what are they going to do when they get out. Other individuals really need services and don’t get it. A lot of cases in the media and in books and TV that we can read about clearly had mental illness and it just wasn’t picked up, or they knew the individual had a serious diagnosis but the medication wasn’t getting monitored or taken properly and that kind of thing. That can lead to more disruption and problems."

Keeping track of prescriptions and closely watching offenders with mental illness can be a costly task requiring millions of dollars and an unavailable number of staff.

After three suicides this past summer in a Washington, D.C. prison, The Washington Times reported that the officers are being asked to monitor, diagnose and recognize mental health issues. The officers said this is simply too much to ask as they are also there for security reasons. The District spent $74.4 million on treatment in 2012, compared to the $50.4 million spent in 2009.

"The police in the District Attorney’s Office are not an occupying army," said Craig Thompson, assistant district attorney in Alamance County. "And people need to realize that if you put people in jail, yes, that keeps them from crime, but you’ve got to support them. And in some states, it's grown. New York City, for example, recently published it costs something like $47,000 a year to keep somebody in jail. That’s insane. You can get a really good ivy league college education for $47,000 a year."

In 2007, CNN ran a report calling prisons the insane asylums of the 21st century. Malesky agrees and said he thinks jails have become the "de facto mental health providers" in many cases.

"Of course, hands down, many people are in prison because they need to be in prison because they’ve broken the laws," he said. "And we need to protect society and they need to be punished. That’s very true, and I’m very supportive of that. But unfortunately some individuals end up in prison and there might have been better diversions or interventions to deal with those specific situations than jail."

While the number of inmates with mental health problems and amount of needed resources doesn't subside, there are possible solutions.

Allison thinks screening processes and hiring more staff could help. The Department of State lists jobs postings for forensic psychologists, requiring a Master's Degree. Turnover is high, meaning even more staff is needed. A strong rehabilitation program could also relieve some of the problem.

"I think the focus should be, ‘What can we do to help them?’" Allison said. "That should be the rehabilitative focus, and most academics focus on rehabilitation and not all prisons do. They focus on punishment, retribution, ‘let’s get this person to pay for their crimes,’ and while that’s not unimportant, we want this person to be able to reintegrate into society afterwards and become useful if indeed they can reintegrate, if it’s not a serious, serious crime where they have to spend significant time. Mental health is a big, big problem in the offender population."

All kinds of rehabilitative-focused approaches should be tried, and these activities, like learning how to interact like others non-aggressively or avoiding substance use, would depend on the disorder at hand, Allison said.

But it's clear that prison is definitely not the solution.

"Of course it’s not the best situation for them," Malesky said. "But the question is, it’s an allocation of resources, and there’s been discussions about that, especially in North Carolina regarding mental health care, and so as long as you continue to cut back, and cutting and restricting and eliminating services, then the outcome is that the people are not going to go away. They’re still going to be there, and in some cases be worse."