Running Head: THE CURRENT MENTAL HEALTH SITUATION IN CORECTIONS

Modern Asylums: The Current Mental Health Situation in Corrections and Implications for
Reform
Brandon McCormick
The Pennsylvania State University

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The Current Mental Health Situation In Corrections
From the Civil Rights Movement, to the passage of the American with Disabilities Act,
and continuing to the present day with the widespread concern for the rights of the lesbian, gay,
bisexual, and transgender community and other traditionally underrepresented groups, many in
American society have prided themselves with their ability to stand up in support of the less
powerful. The stigma surrounding the diagnosis of a mental illness has been greatly reduced in
recent years. Many people have recognized that these individuals require our empathy and our
help, like any other disadvantaged population; however, this effect is not seen equally across all
individuals with a mental illness. People with mental illness who have also been convicted of a
crime still face rampant stigmatization (Hartwell, 2004). According to the most recent reports,
2,220,300 people are incarcerated in local, state, or federal correctional facilities (Glaze &
Kaeble, 2014). At the beginning of the 21st century, an estimated 16% of inmates in prison
facilities suffered from a mental illness (Ditton, 1999). Amongst jail inmates, these rates are even
higher. According to a Bureau of Justice Statistics report, 64% of jail inmates had a recent mental
health problem (James & Glaze, 2006). Furthermore, many of these are severe including: Bipolar
Disorder, Major Depressive Disorder, and Schizophrenia (Abramsky & Fellner, 2003). Recent
research indicates the proportion of inmates with mental illness is likely increasing (Fellner,
2006). As it will soon be made clear, to individuals with mental illness are ill suited to the
correctional environment, and incarceration works counter to treatment goals.
The modern correctional environment is extremely difficult for the normal offender. In
his book Society of Captives Gresham Sykes (1958) highlights the pains of imprisonment that
inmates must face including: loss of liberty, loss of autonomy, lack of heterosexual relationships,
deprivation of goods and services, and lack of personal security and safety. These pains are only

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compounded for inmates with a mental illness. The current paper will first provide a brief
historical overview beginning with the Community Mental Health Act of 1963 and how it
contributed to the mass incarceration of people with mental illness. Next, it will review the
literature in an attempt to explain why, for individuals with mental illness, the correctional
environment is exceptionally difficult and potentially harmful. Specifically, there is an inherent
conflict between the institutional goals of treatment and control, mentally ill inmates generally
do not fair well when integrated into the general correctional population, they are victimized at a
higher rate (Human Rights Watch, 2001, 2003, 2004), and as a result they are often placed on
secure housing units, leading to further harm. All of these issues likely contribute to high rates of
recidivism that perpetuate the cycle of incarceration. Finally, the current paper will examine
promising programs that could lead to institutional reform.
Historical Background
In the mid 20th century, many of Americas mentally ill were treated in large mental
health institutions, also commonly referred to as Asylums. In 1955, 560,000 individuals were
confined to mental institutions; many for long periods of time, and a substantial number of them
remained confined for the remainder of their lives (Conrad & Bandini, 2015). Rothman (1971)
denotes that many of these institutions provided custodial (i.e. housing and feeding) care more so
than effective psychiatric treatment. Due to overcrowding and poor conditions in many of these
facilities, the general public began to call for an end of the warehousing of the mentally ill and
more effective community based treatment (Hartwell, 2004). This public outcry led to the
passage of the Community Mental Health Act of 1963. The creators of this piece of legislation
thought that, due to recent advancements in psychotropic medication and community-based
treatments, mentally ill individuals would be more manageable and more effectively treated in

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the community (Bachrach & Lamb, 1989; Grob 1991). Additionally, state-run institutions were
expensive, and community-based treatment was a promising method for saving taxpayer money
(Conrad & Bandini, 2015). The passage of this act led to the shuttering of many state run mental
health institutions in what is now commonly referred to as deinstitutionalization. However,
these well-intentioned policy changes have directly contributed to current rates of mental illness
in correctional facilities (Hartwell, 2004). After leaving institutions, people with mental illnesses
were expected to seek treatment from community-based programs. Members of many
communities did not want specialized mental health treatment facilities to be built in their back
yard, leading to the problem of not enough treatment options being available for the large
number of individuals with mental illness flooding the streets following deinstitutionalization.
Due to the lack of specialized facilities in many communities, many people with mental illness
were forced to seek care from nursing homes, hospitals, shelters and other programs not designed
for them (Borus 1981; Drake et al., 1998; Susser et al., 1997; Teplin, 1994). Initially, newly
developed antipsychotic medications made it possible for many formerly institutionalized
patients to effectively function in society. Due to a myriad of severe side effects, many
individuals stopped taking their proscribed medication after a short time, leading to a
reemergence of often-severe symptoms (Conrad & Bandini, 2015). Further compounding the
problem, many people with mental illnesses had trouble navigating the confusing changes to
managed care and civil commitment laws following the passage of the Community Mental
Health Act (Laberge & Morin, 1995). Another ingredient to bedevil the situation was the war on
drugs, which has made individuals with a comorbid diagnosis of a severe mental illness and
substance abuse especially vulnerable to incarceration (Hartwell, 2004). According to Fellner
(2006):

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Left untreated and unstable, people with serious mental illnesses particularity those
who are also poor, homeless, and suffering from untreated alcoholism or drug addition
may break the law and then enter the criminal justice system (p. 393).
These factors have combined to make correctional facilities the de facto mental health
institutions of today. Fellner (2006) refers to this phenomenon as the criminalizing of the
mentally ill (p. 393).
Current Trends
Today, the three largest psychiatric institutions in the United States (i.e. facilities that
house people with mental illness) are the Los Angeles County Jail (17,000 mentally ill
individuals), New York City Rikers Island (13,500), and Cook County Jail in Chicago (9,000)
(Parker, 2006). Analysis by Bourdon, Rae, Narrow, Manderscheid, and Regier (1994), indicates
that there are three times as many people with mental illness in correctional facilities than in
devoted mental health facilities. Teplin (1990) administered psychological evaluations to a
sample of over 700 inmates in the Cook County Jail in Chicago, and compared this data to
census data for Cook County. Controlling for demographic differences, the researcher found that
rates of mental illness in the Jail were two to three times higher than in the general population.
Additionally, Steadman, Osher, Robbins, Case, and Saumuels (2009) administered psychological
evaluations of over 800 inmates in five different jails, and found that the prevalence of severe
mental illness (i.e. Major Depressive Disorder, Bipolar I, Bipolar II, Schizophrenia Spectrum
Disorders, and Brief Psychotic Disorder) was 14.5% for male inmates and 31% for female
inmates. Gordon (2002) reports that the most common disorders amongst inmate populations are
Major Depression, Bipolar I and II, and Schizophrenia; therefore, not only are people with
mental illness incarcerated at an extremely high rate, the disorders of these individuals are often

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severe. After they are arrested and convicted (or prior to conviction in the case of some jail
inmates), inmates with mental illnesses face additional institutional hardships.
Treatment vs. Control
The challenge for prison administrators is to balance the often-conflicting goals of the
treatment of inmates with mental illness and controlling them when their behavior is disruptive
or violent. To accomplish these goals, it is vital that administrators identify mental illness as
early as possible. According to a Bureau of Justice Statistics report, 70% of prison facilities in
the United States screen inmates for mental illness. This percentage is lower for jail facilities
mainly due to the transient nature of their populations (Beck & Maruschak, 2001). The goal of
the intake process is two-fold: administrators must evaluate the need for treatment, and, at the
same time, assess the risk an inmate posses to themselves and others. The mental health
screening process is where the conflict between treatment and control begins for many facilities.
This is a result of administrators wanting assessments to focus on information relevant to the
order and safety of the correctional facility, and conversely, mental health professionals are likely
to emphasize diagnostic information. Due to constraints on time and resources, one of these
goals (i.e. facility safety) will likely receive a greater focus at the expense of the other (Adams &
Ferrandino, 2008). The treatment-control conflict does not end there. Fellner (2006) states that:
There is an inherent tension between the security mission of prisons and mental health
considerations. The formal and informal rules and codes of conduct in prison reflect staff
concerns about security, safety, power, and control. Coordinating the needs of the
mentally ill with those rules and goals is nearly impossible (p. 391).
Simply stated, administrators are, understandably, more concerned with the safety of their staff
and other inmates than with the long term treatment needs of inmates with mental illnesses.

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In their daily interactions with inmates with mental illnesses, correctional officers (COs)
also tend to prioritize control over the concern for the treatment needs of the inmates. The
challenge for COs is to maintain order, while also attempting to restrain themselves from
punishing inmates for behaviors produced by the symptoms of a mental illness (Faiver, 1998).
Evidence suggests that COs are rarely successful at this, as inmates with mental illnesses are
punished at a higher rate than the general prison population (Toch & Adams, 2002). After
surveying a number of correctional facilities in the state of Washington, Lovell and Jemelka
(1996) revealed that, although inmates with mental illness made up only 18.7% of the
correctional population in the state, they were charged with 41% of the infractions. Many
behaviors that are the product of a mental illness, including disobeying routine orders to leave a
cell, stand for inmate counts, or take a shower, are routinely punished by COs (Abramsky &
Fellner, 2003). It is possible that many inmates with mental illness (especially severe mental
illness) do not even comprehend when they have broken the rules of the institution (Faiver,
1998). In most correctional facilities, COs have wide discretion when it comes to writing up
inmates for rule violations, and when an inmate with a mental illness is habitually sanctioned for
behavior that may be beyond his or her control, it is done so in disregard for the potential
negative mental health impact it may have (Fellner, 2006). The weight of the blame for this
problem does not lie solely on the shoulders of the correctional officers, as many facilities do not
provide more than minimal mental health training. Therefore, COs may not understand the
behavioral impacts of many disorders, and have difficulty distinguishing between disorder-linked
acting out and the acting out behavior of a disgruntled inmate (Abramsky & Fellner, 2003). Also,
COs are reluctant to be lenient towards inmates with mental illnesses due to concern that it will
encourage other inmates to claim mental illness; thus, leading to a general breakdown in the

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orderly operation of the facility. As a result of the prioritization of control over treatment, there is
a significant disjuncture between the treatment needs of offenders and the resources available for
treatment in facilities across the United States (Clements et al., 2007). This lack of treatment
opportunities seems to be counterintuitive as; effective treatment programs can contribute
positively to the overall stability of a correctional facility. Effective programs have the effect of
lessening symptoms of mental illness, thus reducing the risks of misbehavior and violent
outbursts. Correctional officers are in a unique position to improve the conditions in facilities for
inmates with mental illnesses.
Treatment vs. Control: Potential Reforms
Correctional officers are in contact with inmates for the entirety of their incarceration,
and are in an ideal position to observe and report symptoms of a possible mental illness
(Applebaum, Hickey, & Packer, 2001). COs could potentially act as the front line in the
detection, management, and treatment of mental health problems. However, this would require
that COs be trained, which due to economic restraints could prove difficult. Dvoskin and Spiers
(2004) suggest that COs should be trained and able to provide pseudo-counseling and
psychotherapy (i.e. talk effectively with inmates with mental illness), and be capable of
administering activities and behavioral programs. Along with economic restraints, the attitudes
of correctional officers could also act as a barrier to comprehensive training, as many COs view
inmates with mental illness negatively and as security threat (Applebaum, Hickey, & Packer,
2001). A program in the Wabash Valley Prisons secure housing unit, demonstrates the
effectiveness of even small-scale attempts at CO training. After the implementation of a ten-hour
mental health educational program, there was a marked decrease in use-of-force incidents by
COs and the number of inmate infractions for assault with bodily fluids (Parker, 2006). In

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addition to a pervasive conflict between the administrative goals of treatment and control,
inmates with mental illness are especially vulnerable to the hardships associated with living in a
correctional environment. COs with specialized mental health training may rightfully request
higher rates of pay, which may seem a barrier to progress. However, proper mental health
training my reduce the need for special accommodations for inmates with mental illness, and this
cost-saving measure would likely compensate for increased correctional officer pay.
Environmental Problems
Correctional environments have a high degree of both inter and intra-facility variability.
Some are quite and reserved while others a noisy and active, and environments can vary within
prisons (i.e. different wings) (Toch, 2002). This environmental volatility is difficult for inmates
with mental illness, as it likely leads to anxiety. Furthermore, research conducted by Ax and
colleagues (2007) has identified various environmental triggers for aggression for inmates with
mental illness that are common in the correctional environment. These include frustration in
other inmates and insults from other inmates and possibly staff. Anxiety and aggression are
problematic reactions to the correctional environment, but inmates with mental illness are also
vulnerable to another omnipresent threat in correctional facilities.
Sykes (1958) notes that the lack of personal safety and security is one of the pains of
imprisonment. This pain is even more acute for inmates with mental illnesses. A study that
included a large sample of 7,528 prison inmates found that for male inmates, the rates of staffon-inmate physical victimization was 1.2 times higher than that of the general prison population,
Inmate-on-inmate rates of violence for male inmates with mental illnesses as 1.6 times higher
than the general prison population. Similar results were found for female inmates with mental
illnesses, who were 1.7 times more likely to be victimized by another inmate (Blitz, Wolff, &

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Shi, 2008). The rates of sexual victimization are also higher amongst inmates with mental
illnesses. Wolff, Blitz, and Shi (2007) found that in their study of 7,528 inmates, 1 in 12 male
inmates had been victimized in the 6 months prior to the study (during incarceration), compared
to 1 in 33 for the general prison population. Rates of sexual victimization for female inmates
with mental illness was 3 times higher (24.3%) than the rates found in the general population. To
further complicate this problem, an estimated 15% of male inmates with mental illness and
58.9% of female inmates with mental illness have been sexually assaulted prior to their
incarceration (Ditton, 1999). When combined with the aforementioned problem that many
correctional facilities are unable to provide effective treatment, the situation seems especially
dire, as physical and sexual victimization likely have the effect of worsening a psychological
disorder or producing comorbid diagnoses (Tjaden & Thoennes, 1998). Goodman and colleagues
(2001) note that the need for effective treatment is even greater for those victimized inmates who
had been sexually assaulted prior to incarceration, as repeated trauma is commonly associated
with a poor prognosis. The administrators of correctional facilities are left to deal with this
troublesome situation. They are tasked with finding a solution that protects both staff and
inmates, and is at least moderately conducive with the mental health needs of the inmates.
Segregation and Integration
Carr and colleagues (2006) concluded that when correctional facilities integrate inmates
with mental illness with the general correctional population, it is usually counterproductive to
therapeutic goals. The researchers indicate that this is because inmates with mental illness often
have difficulty with socialization, leading to victimization and acting out behavior that often
results in sanctions. Many correctional administrators have adopted this viewpoint and choose to
segregate inmates with mental illness (especially inmates with severe mental illness) from the

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general correctional population. However, segregation is not ideal, and is possibly equally or
more harmful than integration. Segregation in secure housing units (SHUs) is used to protect
staff and inmates from harmful behaviors, and to protect inmates from victimization or possibly
self-harm (Adams & Ferrandino, 2008). In addition to these pro-social motives, Adams and
Ferrandino (2008) suggest that although expensive, segregation may be a cheaper alternative to
the development and implementation comprehensive treatment plans. Placement in SHUs is not
always permanent, and is often used in response to disruptive behavior from an inmate with
mental illness. Carothers (2003) suggests that the placement of inmates with mental illness in
SHUs in response to disruptive behavior may increase the risk of suicide. This is because these
inmates may interpret the isolation as form of punishment, and are therefore deterred from
sharing their suicidal ideation in the future. A recent report supports this assumption, citing that
the placement in a SHU increases the risk of suicide for all inmates, and especially for inmates
with mental illnesses (Abramsky & Fellner, 2004). Many scholarly works have eluded to the
conclusion that placement in SHUs likely do more harm than good. In a substantial review of
the literature, Smith (2006) concluded that placing inmates with mental illnesses in isolation
causes serious health (mental and physical) problems for a majority of inmates, and these effects
are stronger for inmates with mental illnesses. Recently developed alternative-to-segregation
programs may provide a solution for administrators faced with a seemingly insurmountable
situation.

Segregation and Integration: Potential Reforms

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The McNiel Program, developed in the McNiel Island Correctional Center in Washington
State is one such program. In this program, inmates with mental illness are moved through three
coordinated treatment settings with the ultimate goal of integration into the general correctional
population. The program emphasizes monitoring and counseling in conjunction with the
administration medication by nurses and psychiatrists. Treatment programs such as anger
management and substance abuse counseling are also employed in a low stress environment
(Lovell, Johnson, Jemelka, Harris, & Allen, 2001). Follow-up studies conducted indicated that as
a result of the McNiel program, symptomology associated with mental illness was reduced. The
program was also highly favored by its participants (Lovell, et al., 2001). Similar to the McNiel
program, the Therapeutic Community Program (TC) uses the correctional community as its
treatment modality. The main tenant of the TC program is to improve the socialization skills of
its participants (Saum, et. al., 2007). Studies of the TC program have shown that it is related to
lower recidivism rates amongst its former participants (Wormith, et al., 2007). Empirically
supported programs such as these should be used as an alternative to segregation, or to reintegrate inmates formerly housed in secure housing units.
Recidivism
The lack of effective treatment programs combined with a highly stressful environment, a
high rate of victimization, and possible isolation in secure housing units may exacerbate
symptoms of mental illness, or minimally, do nothing to alleviate them. This reality in
conjunction with ineffective or non-existent reintegration programs, has led to a high rate of
recidivism amongst former inmates with mental illnesses. A study of inmates with mental illness
released from jails in Florida highlights this increased rate. In this study, 32.9% of the recently
released individuals with mental illness had three or more subsequent detentions, and 38.3% had

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one to two subsequent detentions. Furthermore, 44.2% were detained within 90 days of their
release, and a staggering 71.2% were detained again within one year of their release; over a third
of these detentions were for felony offenses (Morrissey, Cuddleback, Cuellar, & Steadman,
2007). Rates of recidivism are even higher for former inmates with a comorbid mental illness
and substance use disorder. One study of inmates in Massachusetts found that 70% of inmates
with a mental illness also screened positive for a substance use disorder, and 90% of recidivists
in their sample had comorbid mental illness and substance use problems (Hartwell, 2004). When
inmates with mental illness are released with little to no improvement in their mental health, they
will almost undoubtedly come into contact with the criminal justice system again. This creates a
revolving door effect for many individuals with mental illness who are arrested, released, and
arrested again, time and time again. Comprehensive, empirically-supported, treatment programs
in correctional institutions would serve to reduce symptoms of mental illness, and therefore
decrease rates of recidivism. However, due to resistance stemming from economic difficulties, or
simple indifference it is unlikely that programs of this type will be implemented in many
correctional facilities.
Recidivism: Potential Reforms
Programs that help with the reintegration of inmates with mental illness upon their
release into the community may be equally or even more effective than in-facility treatment
programs. One such reintegration program is the Critical Time Intervention program (CTI).
According to Draine and Herman (2007),
Critical time intervention (CTI) is a nine-month, three-stage intervention that strategically
develops individualized linkages in the community and seeks to enhance engagement

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with treatment and community supports through building problem-solving skills,
motivational coaching, and advocacy with community agencies (p. 1577).
The CTI program has two major components. First, it works to strengthen the participants longterm ties to services, family, and friends. Second, the program provides emotional and practical
support during the time of transition back into the community. Inmates, especially those with
longer sentences, may have been habitulized to the routine of life in a correctional facility, and
have grown used to their needs being met by the facility. This is a process known as
institutionalization. The CTI program seeks to combat this process by preparing inmates for a
more isolated life in the community. The program rebuilds community living skills, develops
persisting ties to community members, and supports a system of long-term recovery (Draine &
Herman, 2007). When they are released from a correctional institution, many inmates with
mental illness do not know how to effectively live in the community at large. Draine and Herman
(2007), point out that aside from possible parole supervision, the majority of inmates released
from correctional facilities do not have a reentry plan. One of the most serious concerns for
inmates who were recently released from prison is housing. This is especially true for individuals
with mental inmates who were more likely to be homeless before their incarceration. Research
has supported a strong positive relationship between homelessness and recidivism (Draine &
Herman, 2007). The aforementioned CTI program works to correct this problem by
strengthening the connection between recently released inmates and community providers of
reliable housing (Blank, 2006). In a study of the CTI program, Susser and colleagues (year)
found that individuals who were part of the program experienced fewer nights of homelessness
than a control group in an 18-month follow-up. Additionally, follow-up studies of the CTI
program have shown that positive results of the program are maintained even 9 months after

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termination (Susser, et al., 1997). Programs such as the Critical Time Intervention program could
be used to end the current revolving-door phenomenon that is evident in many correctional
facilities.
Conclusion
The Community Mental Health Act was created with the intention ending the
warehousing of individuals with mental illness in state-run asylums, and to improve the lives
of these individuals through effective, community-based treatment. These plans did not come to
fruition as a lack of community based treatment options, and a host of other problems left many
individuals with severe mental illness unable to care for themselves, and put them at a high risk
of coming in contact with law enforcement. Additionally, due to high rates of comorbid mental
illness and substance use disorders, many of these individuals were swept up in the war on
drugs, and its tough on crime policies including mandatory minimum sentences and reduced
judicial discretion in sentencing. This convergence of factors has led to the mass incarceration of
people with mental illness. While incarcerated, the situation for these individuals only becomes
more dire. The administrators of correctional facilities must make tough decisions when
weighing the respective importance of the inherently conflicting goals of control and treatment.
More often than not, due to budgetary constraints, control is the focus of many administrators at
the expense of treatment. Correctional officers also face the same difficult question. Often,
lacking proper mental health training and awareness, COs a prone to mistake behavioral
symptoms of mental illness as the disruptive behavior of an unruly inmate, and therefore punish
accordingly. This overly punitive environment only serves to worsen the environment for
inmates with mental illness and work counter to treatment goals. Interactions with the general
correctional population can be equally damaging, as inmates with mental illness are physically

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and sexually assaulted at a higher rate than the general population. To control their disruptive
behavior or to protect them from victimization, inmates with mental illness are often placed on
secure housing units. However, the total isolation of these units has been shown to worsen the
mental condition of many inmates. A lack of treatment, victimization, deterioration in SHUs,
and a lack of comprehensive reentry plans have led to a high rate of recidivism for individuals
with mental illness. As a result of these factors, the current scenario in the United States bares a
startling resemblance to the situation the Community Mental Health Act resolved to correct; with
the warehousing of a large number of people with mental illness in facilities that lack effective
treatment and do more harm than good.
This situation is not without hope. When faced with a dismal budget allocation for
treatment programs, correctional administrators could still improve the environment of their
facility through the implementation of small-scale educational programs for correctional officers.
Programs such as the McNiel program and the Therapeutic Community program have been
shown to be viable substitutions for placement in secure housing units, do not sacrifice the goal
of inmate control and safety, and would save taxpayers money as integration into the general
population is significantly cheaper than placement in SHUs (Smith, 2006). Finally,
comprehensive reintegration programs like the Critical Time intervention Program have shown
promising results concerning the reduction of recidivism amongst individuals with mental
illness. Over a half of a century later, the goals of the Community Mental Health act have yet to
be realized, but the recent development of empirically supported programs offers hopeful
implications for the treatment of individuals with mental illness in America.

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