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PART I
ADMINISTRATION, ORGANIZATION, AND ETHICS
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Mental Health in Corrections: A Model for Service Delivery
Thomas J. Fagan
The housing and treatment of both criminal offenders and individuals with mental disorders in prisons and jails has been a recurring theme in corrections since confinement became a socially accepted means of punishment (Roberts, 1997). As early as the 1600s, when workhouses were the punishment of the day in Europe, there are documented cases in which relatives confined unruly family members rather than having these individuals tarnish the familiesâ reputations (Spierenburg, 1995). To accomplish this, family members were required to petition a magistrate for permission to confine these individuals. Although many of these noncriminal individuals worked, a minorityâusually from wealthy or distinguished familiesâwere able to avoid labor by being isolated in small homes where the homeowners cared for them.
During the early 1800s, Americans were confining various groupsâincluding criminals, the mentally ill, orphans, delinquents, and the chronically unemployedâin their prisons and jails, often in the same facility (McShane & Williams, 1996). This practice resulted in deplorable living conditions and prompted reformers such as Dorothea Dix to lobby state legislatures for the creation of separate facilities to house the mentally ill. With her success came the advent of mental asylums, the removal of many noncriminal individuals with mental disorders from prisons and jails, and the hope of treatment rather than punishment for these individuals. However, with overcrowding and a lack of adequate treatment staff, the hope of treatment quickly vanished and the warehousing of the mentally disordered in these asylums became the norm.
In addition, with the spread of mental asylums came a new class of mentally ill individuals. These individuals were both mentally ill and criminally dangerous. For these individuals, a number of hybrid arrangements in both prisons and asylums were developed (Morris, 1995). Prisons managed these cases either by housing them with regular criminals or by placing them in separate housing units within the prisons. Some correctional systems even developed separate prison psychiatric hospitals to manage these individuals. Asylums or state hospitals developed secured wards for these types of mentally disordered criminal offenders. These wards provided minimal treatment coupled with the added security found in prisons and jails. This bifurcated system continues even today in many states.
By the early 1900s, medical and behavioral scientists began to play a more prominent role in the thinking and policymaking of corrections. From their point of view, crime could be diagnosed and treated like any other medical condition or illness. As behavioral scientists began to work with prison and jail populations and apply the language and methodologies of medicine to these populations, it became clear to them that these populations were not homogeneous. Rather, offenders needed to be classified based on their security requirements as well as on their mental status (Rotman, 1995). Once again, the idea of segregating individuals with mental disorders from other criminal offenders was reinforced. In addition, the need for mental health treatment staff within the correctional environment became evident. According to Rotman (1995), by 1926, there were more than 100 psychiatrists and psychologists employed in correctional settings.
The medical model, with its emphasis on diagnosis and treatment, prevailed through much of the 20th century. It was applied to both mentally disordered and criminal offenders. Programs and other rehabilitative efforts became the buzzwords within the correctional community. However, by the mid-1970s, there was a growing feeling that few, if any, of these efforts were having any significant impact on the recidivism rate of treated offenders. Much of this pessimism was fueled by reviews of available research at the time, which failed to produce any conclusive links between rehabilitative efforts and declines in correctional recidivism rates (DiIulio, 1991; Martinson, 1974). These findings were sufficient to shift correctional policy away from the medical model.
By the late 1980s, a more balanced view about rehabilitation and correctional programs began to emerge, thanks in part to the extensive research efforts of Canadian social scientists such as Gendreau, Cullen, Ross, and Goggins (Cullen & Gendreau, 1989, 2000; Gendreau, 1996; Gendreau & Goggins, 1997; Gendreau, Goggins, & Smith, 1999; Gendreau & Ross, 1979, 1987), who were able to demonstrate that some correctional treatment programs were effective at reducing recidivism rates. This more balanced view, which is the prevailing approach used in most correctional facilities today, offers a variety of correctional programs (e.g., educational, vocational, religious, mental health, work) to offenders with the hope that offenders will participate in programs that will provide them with the role models and skills they will need to be more productive members of society on their release from prison.
Mental Illness in Prisons and Jails: Current Status
Three factors appear to be contributing to the current rapid rise in the number of individuals with mental disorders found in todayâs correctional environment. First, todayâs âlaw and orderâ sentiments regarding crime, which began during the 1980s, have resulted in a variety of âget toughâ legislative actions, including the abolishment of parole, the introduction of determinant sentencing, changes in competency/criminal responsibility standards, and âthree strikesâ legislation. The cumulative effect of these actions has been to place more individuals in prison for longer periods of time. The number of individuals confined in Americaâs prisons and jails today is fast approaching 2 million. Because some percentage of this population is likely to possess mental illness, the number of individuals with mental disorders will likely increase proportionately to increases in the number of confined individuals.
Second, with the development of psychotropic medications during the 1950s, there has been a national movement toward downsizing the locked wards of psychiatric hospitals in favor of mainstreaming mental health patients and providing them with community-based services. Although this notion was commendable, most state and federal budgets did not provide adequate funding to support these community-based programs. The result has been a dramatic increase in the number of persons with mental illness found among the ranks of the homeless and the incarcerated (Torrey, 1988; Torrey, Stieber, & Ezekiel, 1992). In a de facto sense, todayâs prisons and jails have assumed many of the functions formerly the responsibility of state psychiatric hospitals (McConville, 1995).
Estimates regarding the number of individuals with mental illness in todayâs prisons and jails have varied somewhat. In one study cited by McConville (1995), 37% of men and 56% of women serving sentences of more than 6 months in England were suffering from diagnosable mental disorders. In two studies conducted by the Bureau of Justice Statistics (Beck & Maruschak, 2001; Ditton, 1999), there were approximately 284,000 to 291,000 offenders with mental illness incarcerated in the nationâs prisons and jails in 1998. Using self-report data indicating either a mental condition or an overnight stay in a mental hospital as a definition of mental illness, Ditton (1999) found that approximately 16% of all state prisoners, 7% of all federal prisoners, 16% of all local jail offenders, and 16% of all probationers were mentally impaired. Ditton also noted that state prisoners with mental conditions were more likely that other inmates to be incarcerated for violent offenses (53% vs. 46%), more likely than other inmates to be under the influence of drugs or alcohol at the times of their current offenses (59% vs. 51%), and more than twice as likely as other inmates to have been homeless during the 12 months prior to their arrests (20% vs. 9%). In their annual survey of state and federal correctional systems, Camp and Camp (1998) asked participants to provide the percentage of their offenders who were involved in mental health programs. Reports ranged from a low of less than 1% in several smaller states to a high of 18% in the state of Ohio. Finally, Fazel and Danesh (2002) studied the prevalence rates of mental illness in the prisons and jails of 12 Western countries. They found that approximately 4% of their surveyed sample were diagnosed with psychotic disorders, 10% with major depression, and 47% with antisocial personality disorder.
Third, Americaâs war on drugs has resulted in a dramatic increase in the number of incarcerated individuals confined for drug-related offenses, including use, possession, and/or distribution of narcotics. Begun, Jacobs, and Quiram (1999) reported that the actual number of state prison inmates confined for drug offenses increased from 19,000 (6% of the total inmate population) in 1980 to approximately 234,000 (23% of the inmate population) in 1996. Mumola (1999) noted that the number of federal inmates held for drug-related offenses was much higher and accounted for about 63% of the current federally sentenced inmate population. Interestingly, Camp and Camp (1998) reported that only about 14% of all incarcerated individuals were involved in some form of drug treatment on January 1, 1998.
Using the figures just cited as a rough guide, several observations might be made. First, if approximately 16% of all incarcerated individuals at the state prison and local jail levels and approximately 7% of all incarcerated federal offenders have a primary diagnosis of significant mental impairment, then it is safe to assume that as these prison and jail populations continue to grow, so too will the number of incarcerated individuals with significant mental impairments. Second, if substance abusers who participate in treatment are added to this figure, then an additional 14% of the inmate population may be considered mentally disordered. This figure includes only those offenders seeking treatment for substance abuse. There are many other offenders who decline treatment, some of whom may have a diagnosable substance abuse problem. Last, if better functioning inmates with some mental disturbances (e.g., anxiety and mood disorders, adjustment disorders to incarceration or to medical illnesses such as HIV/AIDS) and personality disorders (e.g., borderline personality disorder, antisocial personality disorder) are added to this equation, then the percentage of mentally diagnosable offenders becomes even higher.
In short, there is a large and growing population of mentally disordered individuals currently confined in our nationâs correctional facilities. Although the placement of mentally disordered individuals in prisons and jails is not a new phenomenon, certainly the number of confined individuals with mental disorders is far greater today than at other times in our history. How correctional settings identify, manage, and treat these individuals has an impact not only on the long-term mental health of this disordered population but also on the work and living conditions found within prisons and jails.
While mental health practitioners work diligently to address the diverse needs of this population within prison and jail settings, correctional policymakers, with growing support from the general public, have begun to examine alternatives to incarceration for nonviolent offenders both with and without diagnosable mental disorders (Schiraldi & Greene, 2002). This movement to seek alternatives to confinement has been aided by a need to contain costs as state and federal revenues shrink during tighter economic times. Certainly, drug and mental health courts, home confinement, reforms in mandatory sentencing laws, and increases in compassionate releases for terminally ill and elderly offenders all are examples of this shift in public sentiment and correctional policy. If these reforms take hold, then they may signal a stabilization, or perhaps even a decline, in the number of future offenders placed in prisons and jails. However, for the current time, correctional mental health practitioners are left with the problem of how best to manage and treat mentally disordered offenders in a setting that does not also embrace rehabilitation as its primary goal and that has limited funds and an expanding population.
Mental Health Services in Prisons and Jails: A Conceptual Model
Providing mental health services in prisons and jails has always been a somewhat contentious subject. When too few services are offered, the psychotic and/or suicidal behaviors of offenders with mental disorders can easily disrupt the smooth and orderly running of a correctional facility. Untreated offenders with mental illness frighten some criminal offenders but may also be victimized by other offenders. Their idiosyncratic behavior often alienates them from other offenders (thereby leaving them isolated), creates housing dilemmas and management difficulties for correctional staff, and may lead to liability issues for correctional administrators. When a broad range of services is provided to offenders with mental illness, cries of coddling criminals are sounded in some public arenas. Others wonder why criminals can have access to services that are sometimes difficult for the average law-abiding citizen to receive.
Assessing which mental health services to offer within a correctional facility can also be difficult to determine and may be influenced by several factors. Certainly, the size and clinical needs of the population being served represent one key factor. The overall mission of the facility in which the services are being offered (e.g., jail, prison, prison hospital, high-security facility, boot camp, private prison) may also be a defining factor. The funding level for mental health services will also be critical. Limited funding obviously results in a limited number of staff available to provide services. When staff resources are restricted, mental health staff are forced to either prioritize their time and offer services only to those whose needs are most immediate and critical or extend the reach of their services by training paraprofessionals to carry out some basic service delivery functions.
Even when adequate funding is available for mental health staff, sometimes it is difficult to find mental health professionals who are willing to work within a correctional environment. Many view this environment as unwelcoming and antithetical to the objectives of treatment. This problem is further compounded by the fact that many correctional facilities are located in rural or remote areas where community-based treatment providers are limited and, therefore, in greater demand. Finally, service delivery may be influenced by the skills, experiences, and treatment biases of the service provider; by the willingness of the service provider to train and use paraprofessionals and correctional staff as treatment extenders; and by the support and respect of correctional administrators for program and service initiatives and staff.
Given all of the preceding conditions and caveats, there are any number of ways of organizing and conceptualizing the delivery of mental health services in a correctional environment. The conceptual model that follows is one way of accomplishing this task. It is meant to provide correctional workers and other readers who may be unfamiliar with mental health servicesâand, more particularly, mental health services within a correctional environmentâwith a conceptual framework through which to view, organize, and evaluate mental health services within prisons and jails.
The conceptual model presented in what follows outlines three levels of service. Level 1 services are basic, are provided to individual offenders, and are often mandated by correctional accrediting bodies such as the National Commission on Correctional Health Care and the American Correctional Association. Level 2 services are offered to specific target groups or populations within prisons and jails and may or may not be mandated by correctional accrediting bodies. Level 3 services involve systemic interventions and/or consultations, often at the institution or agency level. This conceptual model is additive in nature. In other words, Level 2 services should generally not be added until most Level 1 services are implemented, and Level 3 services should not be added until most Level 2 services are being addressed. Presented another way, if the number of service providers is limited, then Level 1 services should be their primary target. If additional staff resources are added, then Level 2 followed by Level 3 services should gain more attention. This model represents one way of prioritizing service delivery when resources are limited.
Level 1 Services
Level 1 services are basic mental health services available to all offenders. Although use of these services may be affected by the demographics of the population being served (e.g., males, females, juveniles, detainees, high- vs. low-security offenders), they represent what should be considered a minimal level of mental health service. Their primary purpose is to provide for the detection, diagnosis, short- and long-term treatment, and referral of offenders with significant mental health problemsâproblems that may be potentially life threatening or that may seriously disrupt the smooth running of an institution. The availability of Level 1 services also serves the secondary purpose of providing offenders with a support system throughout their incarceration. Level 1 services include initial intake assessments, acute crisis intervention, brief counseling, individual psychotherapy/case management targeting primarily the seriously disturbed offender, detention/segregation reviews, special mental health evaluations, and maintenance of mental health records.
Initial intake assessments are typically conducted with one or more of the following purposes in mind:
- To identify emotional, intellectual, and behavioral deficits and/or significant mental impairment
- To ide...
