Mental Disorder Among Prisoners

Toward an Epidemiologic Inventory

Nathaniel Pallone

• Publisher: Routledge
• Year: 2017
• eBook ISBN:
  9781351505741
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

What do we know about the mental health of inmates? What are the implications of what we know? Nathaniel J. Pallone characterizes opinion on these questions as falling into two broad camps: the "tender-hearted," those who see an overlap between mental illness and criminal behavior, and are treatment-oriented; and the "tough-minded," those who have little confidence in psychiatric categories, do not really accept arguments about diminished responsibility, and who feel the emphasis should be on punishment. Which is closer to the truth?

When this book was first published, the incidence of mental disorder among prisoners was nearly four times greater than among comparable groups in the general population in part because prisoners are disproportionately drawn from demographic groups with a high incidence of mental disorder—nonwhite and from lower socioeconomic strata. But other data is equally dismaying: mental retardation is 50 percent higher; alcohol and drug abuse is between five and eight times greater; and neurogenic disorders may be 1,700 times greater. In all categories of mental illness, the incidence among prisoners is far higher than among the general population.

Pallone asserts that evidence suggests that the design and implementation of mental health care needs serious reevaluation, particularly in view of Supreme Court decisions mandating mental health care despite obstacles with implementation. Palone saw mental health care as the primary issue for those who manage prisons. Sadly, this remains as true as when this book was first published.

1

Without Comprehensive Data, Bias Flowers Easily

On a given day in the United States, some 3,300,000 adults, or nearly 2% of the total population over the age of 18, are under the supervision of correctional authorities (Bureau of the Census, 1989, pp. 15,184) as a result of conviction for criminal offenses. Of these, some two million are on probation, 550,000 are serving sentences in correctional facilities, and another quarter million are on parole (Ibid., p. 184), while an additional 130,000 are incarcerated in jails while awaiting trial (Flanagan & Jamieson, 1988, p. 482). Collectively, they constitute the adult “correctional population.”

Cherished Beliefs at Diametric Poles

In the absence of comprehensive data about the state of mental health in the correctional population, several cherished beliefs are afloat in the mental health and criminal justice communities concerning the extent of overlap between the “mad” and the “bad,” to follow the disjunction popularized if not proposed by legal scholar Carol Bohmer (1976). An outrageous belief, deeply cherished among the “tender minded,” holds that:

• All those who commit, or are convicted of, crimes (or at least of serious felony crimes, with “status” offenses like under-age alcohol consumption and similar behaviors that are at bottom merely mala prohibita but not really mala in se bracketed aside for the moment) are, virtually on the face of it, mentally ill. As a corollary, crime is itself the product of psychological disorder, frequently lubricated by biochemical disorder as well; from all of which it seems to follow that the appropriate “treatment” of offenders following conviction should emphasize rehabilitation and be guided by members of the mental health community.
• As a codicil, it is clear that, as we emptied the nation’s mental hospitals over the past 25 years as a function of the advent of psychotropic medication interacting with Federal social legislation in the form of the Community Mental Health Act of 1964, we filled its jails and prisons;¹ and the inescapable conclusion is that the prisons have become the repositories for a visible cadre of the mentally ill who are not “bad” and thus deserving of societal retribution through a punitive criminal justice system, but instead are “mad” and thus worthy of the ministrations of mental health care-givers.
• If you don’t believe it, consider the case of Billie Boggs in New York, or go read maverick psychiatrist E. Fuller Torrey’s (1988) scathing Nowhere to Go: The Tragic Odyssey of the Homeless Mentally III, which effectively portrays, to borrow Katharine Briar’s (1983) phrase, correctional institutions as the new, and “neglected,” asylums.² And consider the historic Pugh v. Locke decision in Mr. Justice Johnson’s Federal District Court in Alabama (1976), which promised to reform the prisons of the nation by requiring not only humane housing and sanitary conditions but also “meaningful programs” staffed by qualified personnel and at least first-line mental health care within prison facilities, so that in the decade after Pugh v. Locke, dozens of states had been placed under Federal court order respecting one or another aspect of prison operation.

At the diametric extreme, there is an equally outrageous and equally cherished belief held by the “tough minded,” to the effect that:

• The very concept of mental illness is an ever broadening and ultimately self-serving construction perpetrated on the public by psychiatrists and psychologists in order to make the necromancy they perform more palatable to fee-payers, including health insurance companies and the tax-paying public.
• As a corollary, the panoply of so-called “mental disorders” contained in the Diagnostic and Statistical Manual of Mental Disorders (Third Edition, Revised, no less), that massive lexicon of sorts and sources of unhappiness purveyed by the American Psychiatric Association, lists a wide array of conditions like “nicotine withdrawal” (coded at 292.00 in that volume) and “caffeine intoxication” (coded at 305.90) that no more deserve to be labeled “mental disorder” than the common cold deserves to be labeled a “physical disorder.” And from that it follows that the appropriate “treatment” of offenders following conviction should emphasize retribution and deterrence; let the shrinks peddle their wares elsewhere.
• If you don’t believe it, consider the wisdom of the Federal Congress in enacting the Kennedy-Thurmond Act of 1984, which effectively eliminated parole in the Federal prison system.³ And don’t forget that, in the 1988 elections, the “Get Tough, Hang ‘Em High” presidential candidate who avowed wider application of the death penalty was overwhelmingly preferred over the candidate whose posture toward prison furloughs bespoke at least an implicit belief in the prison as an institution the purpose of which is rehabilitation, or that regional and local candidates who embraced the same “Get Tough” posture by endorsing mandatory custodial sentencing for all sorts of felony crime were similarly preferred.⁴

The “Penrose Effect”

As in any cherished belief, a kernel of truth is to be found beneath each diametric polarity.

Half a century ago, British psychologist Lionel Penrose (1939) reported a neatly inverse relationship between the number of prison beds and the number of mental hospital beds across the nations of Europe in the 1930s; a quick reading of contemporary data might suggest that what has been called the “Penrose Effect” (Conacher, 1988) is alive and well in the United States (Brown & Smith, 1988; Kramer, 1977). According to data from the National Institutes of Health, the number of beds in public and private mental hospitals declined nationally from 451,000 in 1965 to 177,000 in 1985. According to Bureau of Justice Statistics data, during roughly the same period the number of convicted offenders confined in state and Federal prisons increased from 210,000 in 1965 to 420,000 in 1983, not including in either case those confined in jails or on probation or parole.

In an exhaustive review of the then-current research literature, Teplin (1983), although complaining about methodological flaws (perhaps inevitable, because research in this domain does not readily lend itself to the random assignment of “otherwise similar” subjects to such categories as offender vs. non-offender), concluded that “the research literature offers ... support for the contention that the mentally ill are being processed through the criminal justice system.” In part on the basis of his own earlier research (Lamb & Grant, 1982), distinguished psychiatrist H. Richard Lamb (1988, p. 1147) of the University of Southern California attributes the process whereby mental illness is criminalized to the confluence of a variety of psychological, social, and economic factors:

As a result of deinstiutionalization, there are now large numbers of mentally ill persons in the community. At the same time, there is a limited amount of community psychiatric resources, including hospital beds. Society has a limited tolerance of mentally disordered behavior, and the result is pressure to institutionalize persons who need 24-hour care wherever there is room, including jail. [The result is] a criminalization of mentally disordered behavior — a shunting of mentally ill persons in need of treatment into the criminal justice system.

That process leads to a cadre of “revolving door clientele” (Pallone & Hennessy, 1977) in jail facilities especially, whose crimes are relatively minor and who are generally released at trial, with their sentences reduced to “time served,” after which they return to the same social circumstances from whence they came prior to their incarceration, so that, as Adler (1986) put it, “jails [become] a repository for former mental patients”.⁵ Such evidence may be relevant to the matter of the relative incidence of the “mad” among the “bad,” but it fails to support the correlative contention that mental illness is criminogenic.

Contrary Data: New Facilitiesfor Mental Health Care

To the contrary, it is also the case that we had created some 197,000 “places” in governmentally-supported alcoholism and substance abuse treatment units nationwide by 1985 that simply did not exist 20 years earlier. Absent data which detail what proportion of the 451,000 mental hospital beds (or the 177,000 prison beds, for that matter) of 1965 were occupied by patients or inmates with alcohol or substance abuse disorders, it is of course impossible to correlate these data definitively; but it is a reasonable speculation that the apparent decline in treatment provision for the mentally ill has not been quite so dramatic as an initial reading of the data might suggest. Moreover, during the same period, we had created a network of governmentally-sponsored community mental health centers designed to provide at least first-line mental health care in situ and short of psychiatric hospitalization that simply did not exist in 1965.

Recent empirical studies provide scant support for either side of the controversy over the obverse question — i.e., the relative incidence of the “bad” among the “mad.” Thus, in an investigation of homeless adults, Gelberg, Linne & Leake (1988) reported that subjects who had previously been psychiatrically hospitalized indeed were frequently involved in subsequent criminal activity and tended toward a high frequency in drug and alcohol abuse. In sharp contrast, Phillips, Wolf & Coons (1988), in a study of 2735 previously hospitalized schizophrenics in Alaska over a four-year period, found that only 0.2% to 2.0% were arrested each year for violent crimes, with these arrests accounting for only between 1.1% and 2.3% of annual arrests for all violent crimes in that state.

Toward Sophisticated Guesswork

It is easy to dismiss these polarized biases as clearly simplistic, the product of feverish brains that have particular axes to grind. A more moderate approach might grant that some portion of those who commit serious crimes are indeed seriously mentally disordered, quite apart from whether a specific mental disorder is related to the particular criminal behavior at hand in any way that can reasonably be said to be “causative.”

That more moderate approach might also grant that mental disorders, like physical disorders, come in a variety of shapes and sizes and degrees of severity, some of which, like both the common cold and caffeine intoxication, are essentially self- curable (if not indeed self-limiting) and that people who are seriously mentally ill should be accorded the opportunity for appropriate treatment for their illness, whether that illness is “causative” of criminal behavior, antecedent to criminal behavior, or even engendered subsequently (perhaps as a function of the sanctions imposed for that behavior), in much the same way that dental treatment for an abscess is accorded to even the most cold-blooded predator meritorious of the most severe punishment, even when one is absolutely certain that to withhold such treatment can itself be construed as punitive.

Yet there is no readily accessible body of data that are responsive to the issue of the relative incidence of serious mental illness among those who have been convicted of criminal behavior, whether such illness can be construed as causative or not. Were it the case that a comprehensive census had been taken of the mental health status of the more than three million citizens in correctional custody, on parole, or on probation on a given day in any recent calendar year, one would court little truck with cherished beliefs.

But, despite more than two decades of fairly careful and reasonably scientifically sophisticated data-gathering about an incredible array of sometimes minute aspects of the criminal justice and correctional systems and despite the fact that at least a cursory and untutored categorization of an offender s mental health history is now routinely included in the recommendation made by a probation department in many jurisdictions relative to sanction before sentence is imposed, no such enumerative census yet obtains.

Nonetheless, fragmentary data are available in a wide variety of studies. These data can be consolidated to form a picture that is strongly suggestive, if not quite definitive. The process of consolidation requires a degree of guesswork, with the resultant estimates more or less sophisticated, varying in accordance with the scientific validity of the data bases from which one extrapolates, but also, if truth be told, with the cherished beliefs of whoever is doing the extrapolating and the degree of tough mindedness or tender mindedness brought to the task.

The Burden of Inconvenient Knowledge

In a marvelous passage in his epic Western Star, Stephen Vincent Benet portrays a meeting between John Brown, that “rude frontiersman drunk on God,” and a group of northern liberals led by William Lloyd Garrison of the Boston Liberator who are to finance assault by Brown and his sons on the Federal garrison at Harper’s Ferry. Brown is anxious to describe in detail the technical ingenuity reflected in his plan to scale the palisades of the Potomac. But Garrison and his cohorts decline to hear the tale: “Pray, sir, do not burden us with inconvenient knowledge.”

The most egregiously tender minded, consistent with their conviction that all criminal behavior is the product of mental disorder, will doubtless see the failure to develop a comprehensive mental illness census of the correctional population as the result of a deep desire to avoid the burden of inconvenient knowledge. As sociologist Walter Gove (1982) has proposed, if we avoid labeling those among the “bad” who deserve to be called “mad,” we simultaneously avoid the prescriptions for our own behavior that flow from that second label.

Yet it may be eminently arguable that the adequate “management” of correctional populations, whether in correctional facilities or through probation and parole systems, would seem to require a relatively accurate estimate of the extent of mental illness — and particularly of those varieties of mental illness related to explosive or disruptive behavior—among those in custody or whose behavior is presumably to be monitored, even when such illness cannot be construed as exculpatory or even as particularly related to criminal behavior in any manner than can be called “causative.” In that sense, lack of comprehensive data about the characteristics of members of correctional populations would seem to ill serve even the “Get Tough” crowd. Thus, Steadman, Rosenstein, MacAskill & Mandersheid (1988) have recently complained that, “[i]n developing public policy and designing appropriate services for persons who intersect the mental health and criminal justice systems, one of the major impediments has been the absence of even basic descriptive data.”

One might suspect that the failure to commission enumerative mental health census surveys of the correctional population, in a society which is still quite schizoid in its thinking about what behavior to regard as deviant, about what behavior to label psychiatrically deviant and what behavior to label criminally deviant, and especially about the extent to which mental illness should serve to exculpate or merely to explain criminal behavior, might in some fashion be predicated on an understandable desire to avoid the burden of “inconvenient knowledge.” However that may be, the fact is that two exhaustive studies of the characteristics of incarcerated offenders undertaken by the U.S. Bureau of the Census for the Department of Justice — covering jail inmates in the first instance (1980) and prison inmates in the second (1988) — paid scant attention to the mental health status of respondents while focusing very heavily on patterns of drug and alcohol use.

Further, beyond a first impression that mental health census-taking should represent a relatively easy undertaking among members of a population whose freedom is judicially restricted (an impression that for several technical reasons may prove rather too glib, however, since a comprehensive mental health evaluation that meets contemporary standards for thoroughness may require detailed neurological inquiry as well), there lurk a number of rather significant sets of impediments concerning the issue of whether current mental status at the time of the criminal behavior itself or at the time of the census-taking should be the focal concern.⁶ If the former, one either is required to accept retrospective self-reports or to attempt to amass corroborating evidence from external sources. If the latter, one is left with the question of whether current status at the time of the census-taking itself is in any reasonable way indicative of a prior pattern or emerged as an artifact of confinement. From the perspective of the tasks of managing correctional populations, however, it is the latter and only the latter that holds operational significance.

Notes

1. It is instructive to recall that Mr. Justice Johnson, who handed down the decision in Pugh v. Locke in 1976, the historic case that created the precedent under which ...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Preface
• 1 Without Comprehensive Data, Bias Flowers Easily
• 2 Epidemiological Studies of Mental Health and Illness
• 3 Alcohol and Substance Abuse Disorders
• 4 Neurogenic Mental Disorders
• 5 Reprise: Estimates of Mental Health Staffing Needs
• 6 After-Words: Parables of Convenient Ignorance and Casual Indifference
• 7 General Summary
• References
• Index