cell doorA large number of prisoners in US jails have a mental health issue, but the support systems to help them are often not there – but there are signs this is beginning to change. Mary O’Hara reports.

David Muhammad knows a thing or two about the US criminal justice system and its impact on individuals caught up in it. A former journalist who grew up in poverty in Oakland, California, as a teenager he “wound up” in the foster care system as well as having brushes with the law. But Muhammad was able to turn his life around “pretty quickly” and has worked to overhaul of the prison system for the past two decades as a frontline worker and policy advocate. One of the areas he says needs urgent and focused action is mental health.

As a criminal justice expert whose current roles include director of justice programmes at the National Council on Crime and Delinquency and as an adviser to the rehabilitation non-profit organisation the Anti Recidivism Coalition, Muhammad believes tackling the huge numbers of people with mental health problems behind bars, including many younger people, should be an essential component of broader attempts at justice reform. Criminalising mental illness is wrong on multiple levels, he says. Not only should the system work so that whenever possible people with mental health challenges don’t end up incarcerated in the first place Muhammad states, it should also ensure that those who are in prison receive the treatment they need.

“It’s a huge issue. Prison is not the place where we should have people with mental health challenges yet it has become the default mental hospital,” he explains. “It only makes things worse.” 

Referring to the mistreatment of many people in prison with mental health problems including solitary confinement and restraint he says: “We allow so much to happen inappropriately in the criminal justice system because we excuse it as: ‘these are people who committed crimes’.”

Extraordinary challenge

The scale of the challenge to address the imprisonment of people with mental health issues in the US is nothing short of extraordinary. Part of this is down to what has increasingly been recognised as a wider prison crisis. Muhammad points out that, for example, swathes of the population have been swept up into the system in recent decades, including a disproportionate number of people from ethnic minorities and those with mental health issues and learning disabilities. 

Despite recent efforts to reform the system including early release, reducing sentencing for nonviolent offences and overtures from politicians like presidential contender Hillary Clinton that more is needed to reduce the number of people in jail in future, the US is still the world’s largest jailer with a huge prison population. One in every 35 adults is under some form of criminal justice supervision. The country accounts for 5% of the world’s population but 20% of its prison inmates while the number of prisoners overall has quadrupled since 1980, much of it down to “tough on crime” policies introduced under the Bill Clinton administration, which introduced laws that, among other things, produced harsher sentences.

However, if this bigger picture isn’t already concerning enough, Muhammad argues that the circumstances faced by people who go into prison with a mental health problem, or who develop mental health issues once incarcerated, warrants particular attention in the coming months and years. The US is an example of a system that has not adequately looked after some of its most vulnerable people, he suggests. “There are two different types of people we are talking about. You have people who come into prison with mental health challenges – and it’s a big reason why they came to prison – and then what we still don’t have a good appreciation for is the people who develop mental health problems because they are in prison. And that is especially [problematic] because it’s most often undiagnosed and goes untreated entirely.”

Muhammad points to the fact that the rise in the proportion of people with mental conditions being locked up is linked in part to the deinstitutionalization of state mental hospitals since the 1980s, adding that any strategy to turn the situation around has to take this into account. “There were good reasons for doing that,” he says of the moves to shut down asylums, but the absence of alternative community-based care or other appropriate substitutes, coupled with a tougher criminal justice system, has led to hundreds of thousands of people with mental health problems being trapped in the prisons net. 

There are varying figures around how many people in prison have a mental health difficulty – analysis suggests many go undiagnosed – but some put it as high as between 60% and 80%. A recent report from the Urban Institute said that more than half of all inmates in state prisons and jails have some kind of mental health problem, with depression accounting for the highest proportion (21%). The institute also found that mentally unwell prisoners tend to be in prison for longer, their re-offending rates are higher on average and that they are more likely to be jailed for minor offences.

Another recent report illustrated the extent and nature of the mountain still to be climbed. The Treatment of Persons with Mental Illness in Prisons and Jails, compiled by the Treatment Advocacy Centre and the National Sheriffs’ Association details how the number of people in prison with a serious mental illness – more than 350,0000 – currently exceeds the number in state psychiatric hospitals by 10 to one. And, not only does this number continue to climb, so too does the severity of inmates’ illnesses. 

Meanwhile, despite prisoners being legally entitled to receive medical care, the overall experience of people with mental health difficulties in prisons is disturbing. The report outlines some of the major issues including that mental health conditions often deteriorate due to lack of treatment, that assaults, self-harm and suicides are more prevalent among prisoners who have a mental illness, and that they are relegated “in grossly disproportionate numbers, to solitary confinement, which worsens symptoms.” In one shocking incident, a man in New York with schizophrenia spent 13 years of a 15-year sentence in solitary confinement.

Overcrowding, a lack of investment in mental health professionals within prisons and the reality that corrections officers are not trained to deal with mental health problems, conspire to create a profoundly inadequate system. The report concludes: “The treatment of mentally ill individuals in prisons and jails is critical, especially since such individuals are vulnerable and often abused while incarcerated. Untreated, their psychiatric illness often gets worse, and they leave prison or jail sicker than when they entered.”

Greater priority

Muhammad believes all of these challenges need to be a matter of priority and has made it a core thread of his current policy work. There are examples around the country he says of promising initiatives at different levels of the criminal justice system to prevent incarceration and to push for better treatment. Muhammad points to “street crisis teams” in some cities including Los Angeles and his hometown Oakland as other models of innovation. These, much like street triage teams in the UK, are mobile units where police officers work alongside mental health professionals within communities to help identify and assist those people most in need.

Many cities and counties have been taking action to prevent people ending up in the system by instigating specialist training for police officers to engage with people who may be in crisis, such as teaching them de-escalation techniques. In Miami Dade County in Florida, for example, after the authorities began investing in training police officers in crisis intervention and how to divert people to relevant services, the number of convictions plummeted from 800 to fewer than 100 a year.

On a broader level, a coalition including the Council of State Governments Justice Center, the American Psychiatric Foundation and the National Association of Counties launched a national campaign to encourage local jurisdictions to collect data on inmates with mental health conditions and to adopt strategies to avoid incarceration. 

However, while there are instances where efforts are bearing fruit and there is a greater recognition of the counterproductive outcomes of inadequate and poor treatment – president Obama’s announcement in January of an end to solitary confinement being one prominent example – “we still have a long way to go,” Muhammad concludes. 

More investment

A key strategy going forward should be to re-invest a proportion of any money saved from policies to reduce overall prison numbers in adequate mental health treatment for those who remain behind bars, he suggests. Some of this cash should also be directed towards communities and services that could prevent people in crisis wrongly being caught up in the criminal justice system, he adds.

Associated issues including that mental health budgets generally have been slashed by many states leaving community treatment options lacking must be tackled as part of any efforts to address where criminal justice and mental health intersect, according to Muhammad. 

There is another aspect that must be dealt with, one too often left out of the discussion, he says: if genuine progress is to be made then the fact that poverty tends to be a pipeline to prison cannot be ignored. “The mental health [issue] is compounded by poverty. When you’re wealthy your family is sending you to residential treatment. If you don’t have the resources, you got to jail instead of to treatment.”

About the author

Mary O’Hara is a freelance journalist