In 2005, Deneise Younger went to prison for forging nearly a whole checkbook's worth of checks after a former partner slighted her. A few months into her sentence, she lost her temper with another inmate and placed razor blades in her shoes. For that, she was sent to solitary confinement for 180 days and her sentence was extended another year. While Younger had several of these impulsive reactions in her life, it wasn't until three months into her time in the South Carolina prison system that she was diagnosed with intermittent explosive disorder and manic depression. "I never realized what it was," Younger, 36, told me over the phone. "You just get real angry and without thinking, you act, not knowing that you have reacted or said something stupid until after the fact. When I was putting those razor blades in her shoes, I knew what I was doing, but not in the moment, and afterward I felt so bad. Like, 'Why did I just do that?'"While Younger was able to reflect on her offenses in solitary confinement, the punishment made it difficult to manage her anger and depression. "I was so mad in there. I would beat the door, I would scream and cry. It was awful. I felt worthless, I felt helpless, I felt lost, I was embarrassed," she says. Aside from the psychiatric medication that was dropped off at her cell door once daily after her diagnosis, she didn't have access to any sort of mental health counseling that could help her make sense of her newly identified conditions.
In some instances, guards, officers, physicians, and inmates themselves were unaware that they had a condition like PTSD or a personality disorder for more than two years.
"I only saw the psychiatrist once a month to review how my medication was going, but I would have wanted someone to talk to a little bit more often," she says. "You are already angry, you are already grieving being in prison with all the rules and different personalities and the neglect, it's better when you can talk to someone and express yourself, you know?"
Without anyone to help her cope, Younger ended up in solitary with another impulsive episode and landed on suicide watch for seven days, even though she didn't have any suicidal thoughts or intentions. While this meant that she was checked in on more frequently, again, she didn't receive any sort of mental health counseling during or after the incident.
Unfortunately, Younger's case isn't an outlier. According to the last report by the Bureau of Justice Statistics, nearly 50 percent of US inmates have mental health conditions but only 34 percent of state prison inmates had professional mental health therapy after being admitted to prison; the number is even lower for those in local jails, just 18 percent. So, thousands of individuals had, and undoubtedly have, to navigate America's meager mental health services in correctional facilities. What are they up against? Delayed diagnoses, ineffective and often abusive care, and violence. But denying mental health care, whether intentionally or not, to individuals doing time isn't just unconstitutional, it can create bigger problems down the line: declining mental health, extended sentences, and increased risk of recidivism.
The trouble can start as soon as someone with a mental health condition enters a correctional facility. Like Younger, many inmates receive their first mental health diagnosis in prison, but it isn't right away. In a new study published in April, researchers combed through records of more than 8500 Iowa state prison inmates and found that a whopping 99 percent of mental health diagnoses were first made during incarceration, some as late as 29 months into a prisoner's sentence. That means that in some instances, guards, officers, physicians, and inmates themselves were unaware that they had a condition like PTSD or a personality disorder for more than two years.
Diagnosing mental illness is undeniably difficult in many circumstances, but the way mental health care is currently run in American correctional facilities seems to make it extra challenging to figure out who needs help. For starters, confidential disclosure can be nearly impossible. Michael Bien, a San Francisco-based attorney who successfully sued the state of California for its overcrowded prisons, represents inmates with physical and psychological disabilities and has heard numerous complaints about discretion.
"A lot of prisoners have told me that when they finally got the courage to ask the guards to see a mental health professional, there wasn't any confidential space to do so," he says. "Instead, someone will come over to your cell and talk to you through the cell door. It's loud and everyone can hear you—why would you tell someone you are hearing voices or have thought about killing yourself? It can be completely embarrassing, especially in prison, where there's an expectation to be tough." It may be the reason some inmates are choosing to stay silent, and only get noticed once their condition worsens and they act out.
Delayed diagnosis can also be a part of behavioral issues. "People who are diagnosed late or not at all may act out, become violent, or create problems for themselves or other prisoners," says Tala Al-Rousan, a research fellow at Harvard's School of Public Health who was the lead author on the Iowa state prison study. "These behavioral problems can result in sentences being extended or harsh punishment like solitary confinement that can worsen their condition, leading to more behavioral issues—it's a cycle that can go on for years."
In federal prison, 40 percent of inmates with mental health conditions were charged with rule violations like physical assault, compared to about 28 percent that didn't have them, according to the Bureau of Justice Statistics report above. It doesn't mean that people with psychiatric conditions are necessarily more prone to violence, Al-Rousan says, but it may be that the difficulty of managing symptoms with negligent care and the stressful prison environment contribute to acting out—that connection is still being studied, she adds.
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Lack of staffing—another pervasive issue that heavily contributes to the grim state of mental health services—may mean that mental health professionals only have time for group therapy instead of individual meetings, an arrangement that can force people to clam up. "After we got court orders for California prisons to do group therapy, we learned that some of the sessions were not effective," Bien says. "The sessions wouldn't be tailored to one condition and every time people showed up, there would be different inmates in the group. The whole point of a group is that you are developing relationships and trust with those people. If it's different people every time, you're not going to want to talk about what's really on your mind, especially in prison where you are already worried about confidentiality."
Do we want them to be functional, productive people who are able to hold a job or do we want them to be so disabled by mental illness that they can't function?
Several investigations that have dug into the matter have uncovered shocking and unconstitutional levels of care in prisons and jails. In 2014, the Southern Poverty Law Center (SPLC) and the Alabama Disabilities Advocacy Program filed a lawsuit suing the Alabama Department of Corrections for "grossly inadequate" medical and mental health care that "subjects all prisoners to a substantial risk of serious harm, including unnecessary pain, loss of function, injury and death."
Maria Morris, a SPLC attorney who developed the lawsuit, spent three years interviewing inmates and pouring over medical records and contracts with a team of experts before filing it. She recounted some of the grievances to me, many of which expose why early diagnosis and effective treatment aren't happening. For example, nurses without any mental health education—"essentially like the ones who take your blood pressure at the doctor's office," Morris said—would determine whether an Alabama inmate needed to see a psychiatrist. Without any psychiatric training, how would they know who qualified?
In many instances, inmates saw unlicensed counselors who were technically not supposed to be practicing without close supervision. Therapy sessions sometimes lasted for just five to ten minutes, and occurred weeks apart, even for patients who were severely ill with disorders like schizophrenia. One of her clients, who Morris referred to as "among the sickest people in the system," was locked in his cell for more than 23 hours a day and received all of his "counseling sessions" by essentially shouting through a solid metal door. (The Alabama Department of Corrections did not respond to a request for comment on this.)
Subpar care is only one part of the grim reality of being in prison with a mental health condition. Sadly, many mentally ill inmates are also often abused and denied care, even when it's clear that they are suffering. During interviews with inmates, Morris and her team learned of too many situations that fell into that category. One inmate cut himself on five separate occasions but never received mental health care. Numerous prisoners reported being medicated against their will and were sent to solitary confinement until they would agree to take medication; many have never received a hearing to determine if it's necessary to take medication in the first place. Inmates on suicide watch would be left alone for days at a time—ironically, no one was watching them.
Mentally ill inmates can find themselves in solitary confinement, also called segregation, which is more often a placement that can aggravate their condition. In 2014, the American Civil Liberties Union (ACLU) and the Prison Law Office sued the Arizona Department of Corrections for excessive use of solitary confinement, among other things. "Prisoners with mental health issues in Arizona aren't being adequately treated, so they are accumulating disciplinary charges, which if you have enough, you will work your way into solitary confinement," says David Fathi, director of the National Prison Project at the ACLU, who argued the case for prisoners in the Court of Appeals for the Ninth Circuit.
"But it's completely uncontroversial that solitary confinement exacerbates preexisting mental illness and impacts the suicide rate, so it's really a lethal combination." An analysis of inmates in New York City jails found that more than 50 percent of self-harm occurred in solitary confinement and another study found that its associated with an increased risk for PTSD upon release.
Morris also told me about instances where mental health symptoms were confused with acting out. A client of hers that was schizophrenic was responding to voices in his head instead of following guards' orders. He was beat up by them and placed into segregation for lack of compliance. "Sometimes people are definitely put into segregation because they have done something violent which may or may not be related to a mental health problem…but there are also people who get placed into segregation in Alabama for essentially being hard to manage and I think certainly a lot of those individual are individuals with mental health problems. Unfortunately, mentally ill people are more susceptible to the harms of segregation, than people who aren't mentally ill," Morris said.
One of the most difficult things to hear Younger recall was the physical and verbal abuse directed toward mentally ill inmates, including herself. "There were some guards that would just do picky things to spite you, like turn off the TV early or threaten to put you in lockdown," she says. "There was one time where they harassed a woman who had some real bad issues. This one particular guard took her cigarette and told her she wasn't getting any more. She was trying to get the cigarette back and they maced her, hit her with the radio, and the other guards handcuffed her. Blood was everywhere. I went through a lot of emotions seeing something like that: I was angry, I was scared, I cried. If you could do something like that to someone who really really really didn't do anything, what would you do to me?"
According to a 2015 report by Human Rights Watch, "corrections officials at times needlessly and punitively deluge [prisoners with mental disabilities] with chemical sprays; shock them with electric stun devices; strap them to chairs and beds for days on end; break their jaws, noses, ribs; or leave them with lacerations, second degree burns, deep bruises, and damaged internal organs. The violence can traumatize already vulnerable men and women, aggravating their symptoms and making future mental health treatment more difficult."
"There is a very serious problem with a lack of accountability in regards to what [prison staff] can do," Morris says. "And I think when you add someone who is seriously mentally ill to the mix, the lack of accountability becomes even greater because those prisoners have a hard time getting people to believe what they are experiencing in prison…the men who are severely mentally ill in Alabama seem to be particularly vulnerable to violence by the guards."
In order to begin to repair the broken mental health system, it's clear that prisons desperately need to hire more professionals, and more qualified ones. According to Morris, the Alabama Department of Corrections maintained that their conditions were largely related to dried up funding. "It essentially boiled down to 'We are doing the best we can. We don't have any money, we can't hire more people, we can't hire more psychiatrists because there aren't any more in Alabama,'" she says. "And that's probably true. It's hard to hire for this position because it's a difficult work environment without good pay."
If facilities can only make do with the workforce they have, additional training for both medical staff and officers could lead to better outcomes for inmates. "These are very difficult situations for psychiatrists to navigate and we are presumably as well-trained as anybody to take care of mental illness," says Elizabeth Ford, a psychiatrist who runs New York City's Correctional Health's psychiatric services and oversees mental health care at Rikers Island. "Yet most patients are in settings where most of the staff aren't trained anywhere close to that and are being asked to manage some of the same things. A lot of New York City jails are trying to change that and train staff as best as they can."
When resources are tight, prisons could turn to other, relatively obvious networks for clues on an inmate's mental health. "It would be helpful to get information from an inmate's former provider or a clinic in the community there they were receiving care," Ford says. "But it can be challenging because there's this idea that once someone enters the criminal justice system, you shouldn't be sharing information back and forth with the community. That's enormously challenging." When Al-Rousan spoke with prison psychiatrists in Iowa, they echoed that having access to patient records would enormously help with diagnosis.
Perhaps one of the reasons why mental health care isn't a priority in correctional facilities goes back to the unfavorable attitude that society possesses toward inmates. "Right now a lot of people have the perception that the people in prison should be punished since they are criminals," Fathi says, adding that there's a need for a cultural shift that recognizes the importance of humane and responsible care. "But under the US Constitution, prisons and jails have to provide mental and medical health services that comply with the 8th Amendment—no cruel or unusual punishment. Most prisoners are eventually going to get out and they are going to live down the street from you and me. Do we want them to be functional, productive people who are able to hold a job or do we want them to be so disabled by mental illness that they can't function?"
Morris added, "When we sentence someone to prison, we are taking away a lot. There is no question that if you go to prison, you are being punished. It's loud, it's smelly, and you have no freedom to do much of anything. You don't have the ability to talk to people you love or to touch the people you love—you lose a lot. But to make someone who is ill suffer from that illness as a punishment is just inhumane. They didn't want this condition, they didn't create it, and they have to be punished more as a result of it? It doesn't seem right—it just seems cruel."
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