Locking Down the Mentally Ill

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Solitary Confinement Cells Have Become America's New Asylums

"If you want to know where they are all being kept," said Todd Winstrom, "they're down in the hole."

Winstrom, a staff attorney for Disability Rights Wisconsin, was talking about what happens to mentally ill offenders when they enter his state's prison system. Without treatment options–and without anyplace else to put them–these prisoners quickly end up in solitary confinement, where they may remain for months or years.

Since solitary confinement has been shown to cause severe psychological trauma in prisoners without underlying psychiatric conditions, it would be difficult to imagine a more damaging place to incarcerate the mentally ill.

Winstrom was quoted by Jessica VanEgeren of Madison's Capital Times as part of her June 10, 2009 investigative report on mentally ill inmates in Wisconsin correctional institutions. VanEgeren, who led a breakout session on "Treatment of Mentally Ill Offenders" at this month's 5th annual H.F. Guggenheim Symposium on Crime in America at John Jay College of Criminal Justice, described a destructive cycle in which these prisoners–untreated, unmedicated, and sometimes undiagnosed–were placed in "segregation" and left isolated in their cells for 23 hours a day.

At three prisons involved in a recent state audit, she reported, between 55 percent and 76 percent of the inmates in segregation were mentally ill.

Wisconsin is far from alone in these practices. While there are no national statistics to indicate how many mentally ill prisoners end up in lockdown, a 2003 report from Human Rights Watch, based on available data from states around the country, found one-third to one-half of prisoners held in what are usually called "secure housing units" (SHUs) and "special management units" (SMUs) were mentally ill.

The report concluded that "persons with mental illness often have difficulty complying with strict prison rules, particularly when there is scant assistance to help them manage their disorders….eventually accumulating substantial histories of disciplinary infractions, they land for prolonged periods in disciplinary or administrative segregation."

The "Worst of the Worst"

Investigative reporting has been key in exposing the treatment of mentally ill inmates in solitary confinement in several state prison systems. Last year, a series of articles by George Pawlaczyk and Beth Hundsdorfer in the Belleville (Illinois) News-Democrat documented the treatment of mentally ill inmates at Illinois's Tamms supermax prison. At Tamms, prisoners deemed "the worst of the worst" are kept in virtually permanent lockdown, in conditions that "some critics say amounts to torture worse than that experienced by suspected terrorists at the U.S. military prison camp at Guantanamo Bay."

[ED NOTE: Pawalczyk and Hundsdorfer won the 2010 John Jay/H.F. Guggenheim Award for Excellence in Criminal Justice Reporting (series category) for their work.]

The News-Democrat chronicles the story of Faygie Fields, a diagnosed paranoid schizophrenic who was in and out of Chicago mental hospitals before he, like so many others, made the short leap from asylum to prison. In prison for murder since 1984, Fields exhibited behavior typical of many inmates with untreated or undertreated mental illness: He was unruly and sometimes violent with guards, and he threw food, urine, and anything else he could get his hands on. When Tamms opened in 1998, Fields became one of its original residents.

After he had been "held alone and often naked in a segregation cell for nearly six years," the paper reported, two psychiatrists brought into the prison examined Fields and his medical records and diagnosed him as a schizophrenic in urgent need of treatment. Fields' schizophrenia diagnosis had been dismissed by two Department of Corrections psychiatrists and Tamms' supervising psychologist, who thought he was faking his behavior. The latter testified, in a court case on prison conditions, that his self-mutilation was part of something prisoners did to "compete with each other to see who can cut because it's fun."

Faygie Fields was eventually moved to a mental health unit at Tamms, where he receives treatment but still lives in solitary. The 30 years added to his original sentence for offenses committed in prison mean that he will likely die there.

Pawalczyk and Hundsdorfer's reporting helped fuel hearings on Tamms by the Senate Judiciary's Subcommittee on Human Rights, as well as a "ten-point plan" for reforms at the prison, released by the Illinois Department of Corrections in September 2009. (Critics say that while the plan does call for certain improvements, it does not address many of the abuses at Tamms, particularly those concerning treatment of the mentally ill.)

Media coverage of the issue has been influential in other instances, as well. In a 2007 series for the Portland Phoenix, Lance Tapley described scenes that "might have taken place in Abu Ghraib" and practices that "fit some classic definitions of torture" in the Maine State Prison's SMU, including spraying mace on unruly mentally ill prisoners and binding them, naked, in "restraint chairs." Tapley's reporting helped fuel a campaign that led to the introduction of a bill in the state legislature to limit the use of solitary confinement in the state's prisons–and virtually ban it for the mentally ill.

In 2001 in New York, Mary Beth Pfeiffer, a reporter for the Poughkeepsie Journal, began investigating prison suicides, leading to a series of articles exposing the treatment of mentally ill inmates in the state's SHUs. In subsequent years, a full-fledged movement grew around the issue of mentally ill prisoners in solitary, beginning with a 2002 lawsuit to restrict the practice filed by the advocacy group Disability Advocates.

Lockdowns

The movement's ammunition came largely from a 2003 report by the non-profit Correctional Association of New York. The group had visited nearly all of New York's 26 SHUs, where some 5,000 prisoners were held in lockdown for periods that in some cases lasted 23-hours-a-day or more. Its report found that a quarter–and in some units as many as half–of the prisoners were "identified as seriously mentally ill." The SHUs held about 10 percent of the system's prisoners, but accounted for nearly half of its suicides.

A third of the SHU prisoners engaged in cutting or other forms of self-mutilation. "Unthinkable to outside observers," the Correctional Association said, "the Department [of Corrections] issues misbehavior reports to inmates who attempt to kill or harm themselves"–and the punishment was often more time in lockdown. While the state's prison population had tripled in the previous 20 years, it still had the same number of places–just 200–in its sole psychiatric center. The Correctional Association's Executive Director Robert Gangi would later describe placing mentally ill inmates in solitary as "state-inflicted brutality."

After the release of the Correctional Association report, the chair of the New York Assembly's Corrections Committee, Jeffrion Aubry, held hearings and introduced legislation to improve treatment for mentally ill inmates and forbid their placement in SHUs. By the following year, a coalition of advocates for prisoners' rights and the mentally ill were organizing a "Boot the SHU" campaign, with the slogan "Think Outside the Box."

In time, the legislation passed in both houses of the state legislature with broad bipartisan support and was endorsed by newspaper editorial boards across the state and by the New York State Correctional Officers union. But it faced opposition from Department of Corrections leadership. In 2006, then-Governor George Pataki vetoed the bill, saying prisons needed to be able to use solitary confinement to protect inmates and staff "from those who are unwilling to adhere to even the most minimum levels of civilized behavior."

Then-Governor Eliot Spitzer finally signed a version of the bill–with some compromises brokered to reduce costs–at the start of 2008. Its sponsor, Assemblyman Aubry, spoke of the legislation as a victory for public safety as well as for mentally ill inmates themselves, who "would complete their entire sentence in SHU and then go back into the community without being adequately treated. It might have kept the prison system safe, but it wasn't safe for the public having these people confined and made worse and then sent back into the community without."

The legislation came atop a 2007 settlement in the lawsuit by Disability Advocates, which will sunset when the law goes into full effect in 2011. In theory, New York State has made a commitment–within limits–to move existing mentally ill prisoners out of solitary confinement, and keep new ones from being placed in lockdown.

In practice, this is a complicated task.

Under the terms of the settlement, the state is now required to provide the mental health screening of all incoming prisoners. This screening is conducted in one of the state prison processing units by a state Office of Mental Health team, usually consisting of clinicians--psychologist, social worker, and/or therapist--and overseen by a psychiatrist. The team has every inmate fill out a questionnaire asking whether they have attempted suicide, thought about doing so, and so on. If the person is judged to be seriously mentally ill, the psychiatrist will make the final diagnosis and prescribe medication–no simple matter, since prescribing psychotropic medications is a highly inexact science, and requires frequent follow-ups to make sure the drugs are working.

"Most mentally ill people also have individual counseling sessions, on a weekly to monthly basis, plus at least one psychiatric session every three months," Dianna Goodwin, the staff attorney at Prisoners' Legal Services of New York in Albany who monitors the settlement, said in a telephone interview with the authors. The monitoring includes two visits of the prisons a year, and continual oversight of prison hearings on discipline problems that involve mental health.

If an inmate is judged to suffer from serious mental illness--conditions that include schizophrenia, bipolar disorder, serious depression, and psychotic or delusional disorders--he or she can still be placed in a solitary cell. But according to the settlement, these prisoners must be allowed out every day for one hour of exercise and two hours of treatment. The new law, which is considered by advocates to be stronger than the settlement terms, demands four hours of treatment–two back-to-back, two hour sessions of therapy--plus one hour of exercise each day.

In some instances inmates will be sent to live in a facility prepared for the mentally ill. In other instances they may stay in other prisons, but in sections especially organized for them--where, for example, some parts of a steel cell door may be replaced with mesh screening. In either setting, the prisoners are supposed to be overseen by mental health clinicians as well as guards who receive training in how to handle mentally ill patients. In December, the state opened the 100-man Residential Mental Health Unit at the upstate Marcy Correctional Center, Goodwin said that the state hopes to increase the unit's capacity to 200.

Confining the Mentally Ill

There are other places for the mentally ill scattered throughout the system. When the Marcy unit opened, the New York State Department of Corrections said that only about 200 prisoners with serious mental illness were in SHUs for disciplinary violations. (The state says it does not use "solitary confinement.") Of its 58,690 inmates, 7,844 were diagnosed with mental illness, including 2,359 with serious mental illness, a DOC spokesperson told the Associated Press in December. These numbers are different from the 2003 findings of the Corrections Association, which estimated a quarter of the 5,000 inmates in SHUs were seriously mentally ill.

What comes into play here, of course, are the methods for classifying prisoners. Critics say that the Office of Mental Health tends to be overly conservative in assessing an inmate as seriously mentally ill, with things like personality disorders, PTSD, or the effect of head trauma often not considered "serious."

And the view still lingers–among the public as well as the DOC–that inmates are likely to con them, claiming mental illness to excuse bad behavior or get an easier berth in the prison system. According to Nina Loewenstein, the staff attorney at Disability Advocates in charge of the lawsuit and settlement, mental health professionals do the initial screening and monitor inmate care.

But decisions about who to put where and for how long are still made by the prison administration. If there is a review–and in many cases there need be no review, Loewenstein says–an inmate's future is determined by prison officials, which includes doctors, but no outside representatives. In other words, if a prisoner wants to contest a decision, he can't have his own attorney or psychiatrist present to advocate on his behalf. Still, Loewenstein believes there already are improvements in the overall process, with the prisons sometimes suspending sentences or cutting them back in duration due to recognition of mental illness.

Even the legislation, which most advocates see as stronger than the court settlement, does not ban the use of solitary confinement for all mentally ill inmates. Prison officials can still segregate such prisoners when they deem it necessary for the safety of staff, other prisoners, or the mentally ill inmates themselves, or when those inmates refuse to participate in treatment. Finally, the law does not apply to prisoners held in local jails.

Dianna Goodwin of Prisoners' Legal Services acknowledges these problems, and would like to see the program opened up to more people. One major issue, she said, "is that they don't do a whole lot with PTSD. Almost everyone in prison has it. It is not part of the lawsuit or the statute, but it is a huge problem."

Prison life brings "ongoing trauma," Goodwin added, "so people with bad PTSD have all kinds of triggers that aren't being addressed as a mental health issue. I don't know what kind, if any, of training they have for correctional officers on this issue."

Nevertheless, she declared that, overall, "there is a very sincere effort by both Corrections and the Mental Health Office to put everyone who they classify as seriously mentally ill into an appropriate program." While top officials at the DOC had resisted the legal sanctions and earlier denounced the Correctional Association report, corrections staff who deal with mentally ill inmates on a daily basis tend to welcome the changes. "The correctional staff has told us over and over again that even long time officers are coming on board, since everyone knew they had a problem dealing with these prisoners," Goodwin said. "Mentally ill people have been incarcerated in unprecedented numbers since the closure of most community mental facilities over the last decades; DOC has had to handle the change but until the settlement did not have the resources or institutional commitment to deal with large numbers of mentally ill inmates."

A Step Towards Decency

While most advocates see the settlement and especially the legislation as what a 2007 New York Times editorial called "a step toward basic human decency," Few believe that it goes far enough. "Maltreatment of mentally ill prisoners is a national shame," the Times editorial continued. "The basic problem is that severely ill inmates should not be held in lockdown at all." In the eyes of some critics, what New York and a handful of other states have done is simply reduce the frequency and severity of a practice they equate with torture.

The UN Human Rights Committee, European Committee for the Prevention of Torture, Amnesty International, and Human Rights Watch have all, in various terms, deemed long-term solitary confinement cruel and unusual punishment for all prisoners. A 2003 Human Rights Watch report stated: "Even if they have no prior history of mental illness, prisoners subjected to prolonged isolation may experience depression, despair, anxiety, rage, claustrophobia, hallucinations, problems with impulse control, and/or an impaired ability to think, concentrate, or remember."

When it comes to mentally ill prisoners, several U.S. Courts have joined in denouncing the use of any segregated confinement. In the most famous of the relevant cases, Madrid v. Gomez, a federal judge in California declared that solitary confinement "may press the outer bounds of what most human beings can psychologically tolerate," while for mentally ill prisoners it is "the mental equivalent of putting an asthmatic in a place with little air to breathe."

No widespread ban on the lockdown of mentally ill prisoners is likely to take place without changes in the trend toward criminalizing the mentally ill, which has been underway for more than 20 years. In 2003, Human Rights Watch concluded that America's prisons and jails held three times as many mentally ill people as its psychiatric hospitals. The Los Angeles County Jail and New York's Rikers Island effectively functioned as the nation's two largest inpatient mental health facilities, and incarceration had become its default treatment for mental illness.

According to Bureau of Justice Statistics data more than half of all prison and jail inmates self-report that they suffer from mental health problems–five times the rate in the general population. According to the National Alliance on Mental Illness approximately 24 percent of inmates in U.S. prisons and 17 percent of those in local jails have what would be diagnosed as serious mental illness.

Non-Violent Offenders in Majority

In the session on mentally ill inmates at last week's H.F. Guggenheim Symposium, Dr. Fred Osher, Director of Health Services for the Council of State Governments Justice Center (CSG) , said the majority of mentally ill people in prisons and especially in jails are serving time for non-violent offenses, including minor drug offenses and so-called "quality of life" crimes associated with homelessness and substance abuse, As a report from the CSG's Criminal Justice/Mental Health Consensus Project in 2002 puts it, many "have been incarcerated because they displayed in public the symptoms of untreated mental illness." Osher said that the prison environment–noisy, overcrowded, predatory–inevitably causes these symptoms to get worse.

While corrections systems need to improve the ways they assess and treat mentally ill people, the fact of their incarceration in large part represents a failure of the mental health system.

Many end up in jail only because they are overlooked, turned away, or intimidated by an overburdened, underfunded, and inadequate network of mental health services. "People with mental illness," the project's report says, "are falling through the cracks of this country's social safety net and are landing in the criminal justice system at an alarming rate."

Also present at the H.F. Guggenheim Symposium was Robert Carolla, Director of Media Relations for the National Alliance on Mental Illness (NAMI). Carolla agreed that the problem of the incarcerated mentally ill has its roots in the American mental health care system. Following widespread de-institutionalization, he said, budget restrictions kept the mentally ill from getting the community-based services that were supposed to replace inpatient psychiatric care.

"Without state and local mental health services," said a NAMI fact sheet issued last month, "too many people living with mental illness end up in encounters with police or warehoused unnecessarily in jails and prisons."

In other words, the prison became the new asylum. And the money withheld from mental health services, Carolla said, was simply pumped into law enforcement and corrections–along with much more, since the transition from asylum to prison is anything but cost-effective. State corrections spending has more than tripled in the last 20 years, when "what is needed instead," the NAMI publication argues "is investment in mental health treatment and recovery services to minimize costly criminal justice involvement of persons living with serious mental illness."

Such funding for mental health services, as NAMI puts it, "also is an investment in recovery and saving lives of persons who struggle with medical illnesses." Even more than the modest corrections reforms won in New York and elsewhere, this shift in priorities might serve to reduce the number of tortured, anguished hours lived by people with mental illness, alone in their solitary cells.

James Ridgeway, a veteran investigative journalist, is senior Washington correspondent for Mother Jones. Ridgeway and Jean Casella, a freelance writer and editor, recently launched the web site Solitary Watch News, aimed at providing the first centralized source of information on solitary confinement in the United States.

*Photo courtesy Jenn Ackermann. See her award-winning photographs of the mentally ill in confinement here.

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