Recognizing Mental Illness in Inmates


By Michael Grohs, contributing editor

In a famed episode of The Twilight Zone called “Time Enough at Last,” Burgess Meredith played Henry Bemis, a henpecked bookworm who gets his wish when a nuclear war annihilates everyone but him and leaves him in peace with a lifetime of needed supplies and the entire collection of books from the public library. When he gets settled and leans over to pick up his first book to finally read in peace, his Coke-bottle glasses fall off and break. He is left alone with nothing. He was in solitary confinement in a very large cell. The audience most likely considered the irony of the situation, but probably ignored thinking about what came next. What happened to Henry Bemis one year later? Five years later? Ten?
With the closing of state mental health hospitals and the subsequent amped up war on drugs, prisons have been flooded with people who have mental health issues, in many cases, severe ones. John Wilson, PhD, CCHP-MH, who is MHM’s vice president of Clinical Development, says, “Current rates of mental illness in jail settings are reported to be 30% to 40% in male detainees and 50% to 60% in female detainees. 
“In prisons, rates are somewhat lower, but correctional authorities can still expect about one in five male inmates and two in five female inmates to suffer from a diagnosable mental disorder. These estimates can be used as rough benchmarks in correctional systems, with the implication that lower rates may reflect under-detection,” he says.
In California alone, says Bill Sessa, information officer at the California Department of Corrections and Rehabilitation, nearly 38,000 inmates—a third of the population—receive some form of mental health treatment. “The need for mental health treatment is significant among both jail and prison populations and our effort to provide it is a significant aspect of our operation, some of it in cooperation with the Department of Mental Health.”  The CDCR’s budget for mental health services in 2015 alone was nearly $400 million.
That is a significant amount of mental illness, and correctional officers (COs) may not have had formal training in recognizing it or dealing with it. Recognizing mental health matters upon intake is one thing. Says Wilson, “Most correctional systems have an intake screening and assessment process that specifically inquires about past mental health problems, inpatient and outpatient psychiatric treatment, psychotropic medications, symptoms, and medications.” 
A discussion about family history and functioning prior to incarceration can also be a valuable tool to assess the risk of mental health issues. The screening process also includes observation of the inmate’s manner and mental status.  “If patients exhibit the need for mental health treatment, they are placed on an ongoing mental health caseload and checked periodically, typically with a minimum frequency of every 30 to 45 days.”
There are, says Wilson, certain well-known high-risk times for mental health issues and suicidality. One of them is the first 24 to 48 hours of incarceration, upon return to jail or prison from court hearings, parole violations, withdrawal from substance use, placement in restrictive housing, or receiving news related to family loss or notifications of new charges.  Staffs are trained regarding these risk periods, and most correctional systems follow standards that require mental health screening or assessment during these periods. One issue, though, is that not all inmates discuss their mental health needs at all or feel uncomfortable discussing them. “Cultural, racial, and gender differences between the inmate and the mental health staff can be a barrier to communication, and if there are no opportunities for private and confidential interviews, the inmate is unlikely to become a patient.  Experienced correctional administrators and staff can typically point to more than one inmate suicide in which no warning signs were given prior to the inmate taking his/her life.”
Dementia on the Rise
Many inmates arrive at the facility with a mental health condition, but as a result of the mandatory minimum sentencing, inmates convicted of drug crimes in the 1980s are now reaching the age in which dementia might set in, and if an inmate spends most of his or her time in a cell, the condition might go unnoticed for years. Wilson notes that the rise of dementia in correctional settings continues to be a significant challenge and is growing more frequent.
Dementia can manifest in numerous ways, but it usually involves difficulty in inmates following directions for complex sequences of behavior, remembering how to get back to their housing unit, or what they are doing.  Other signs such as self-neglect and poor hygiene may also indicate dementia.  Correctional officers need specific training in recognizing these signs and referring the inmate for a mental health evaluation.  “If dementia is confirmed, these inmates will need special accommodation and support within the correctional system and may qualify for a medical furlough or compassionate release near the end of the disease process.”
Wilson furthers, “Inmates may also be more likely to suffer from dementia earlier due to head traumas or the sequelae of severe substance use disorders associated with their impulsive lifestyle.” Milfred Holmes spent five years as a CO for the Dakota County Jail in Minnesota where he “worked every aspect of the job.” He is currently writing his master’s thesis in psychology with the intention of returning to the correctional world and working with inmates suffering from mental illness. When asked how much training he had gotten as a CO in regard to recognizing mental illness in inmates, Holmes replied, “None. That’s how I knew I wanted to be a part of this industry.” Holmes is well aware of the effects trauma can have on mental well-being. “These guys fight all the time, and the moment they fall, they get kicked in the head.”
Recognizing Symptoms
In some cases recognizing mental illness is more apparent than others. Holmes recalls a time at intake when an inmate dropped to his knees and started speaking into the drain. When asked what he was doing, the inmate replied, “I’m talking to my family. They live down here.” Other times the signs are more nuanced and go unnoticed. Other times it remains hidden. Just last month, former New England Patriot Aaron Hernandez hanged himself in his cell.
At CDCR, training begins even before intake. “Training in recognizing symptoms of mental health problems is included in the academy that all cadets go through before they become correctional officers. Their main purpose is not to diagnose a problem but to recognize an inmate who may be in need of referral to a mental health professional,” notes Sessa. On intake, the staff that has primary responsibility for recognizing mental health problems is professional psychiatrists and psychologists and mental health nurses. All inmates undergo a thorough assessment of their mental health (and other) needs when they first arrive at the facility. That can be the first opportunity to recognize that an inmate needs specialized mental health care. “Inmates already in the CDCR system are diagnosed by mental health professionals (psychologists and psychiatrists), some of whom work for the Department of Mental Health even though they are assigned to our prisons.”
Signs of Suicide Risk
Wilson notes that correctional systems that follow the standards of the National Commission on Correctional Health Care (NCCHC) provide annual comprehensive suicide prevention training to all employees. Correctional officers, medical and mental health staff, staff who provide case management, substance use disorder treatment, and other services attend this training, which includes the signs and symptoms of mental disorders and “implicit as well as explicit signs of suicide risk.”  Often, says Wilson, the inmates who hide suicide ideation are at the highest risk, so it is important to pay attention to inmates’ behavior as well as what they say.
The reason he left the position he enjoyed, says Holmes, was the bureaucracy. (He was at one point sanctioned for having never put anyone in solitary.) For example, COs were given 20 minutes to do rounds and would be written up if they took 30 minutes despite that “talking to a potentially suicidal inmate is why we do rounds.” He also noticed an exaggerated culture of “safety first” at the deficit of helping inmates. An inmate who may or may not have had a mental illness and even raised his voice, which suggested aggression, may have had his arms, feet, and constrained to a chair and wearing a spit guard. “So he’s sitting there with fifteen deputies standing around, his heart pounding, his circulation in his arms cut off and thinking, ‘Oh, now you want to talk to me?’”
Limits on Solitary
Solitary confinement has been a topic of discussion for some time. In 2013, Tom Clements, executive director of the Colorado Department of Corrections and a man who dedicated his life to public service, was shot and killed when he opened the door to his Monument, Colorado, home.  Clements was a reformer with a mindset to improve mental health services to inmates and to reduce the use of solitary confinement in prison. Evan Spencer Ebel, the parolee suspected of killing Clements, spent much of his eight years in prison in solitary confinement.
Wilson says that the impact of solitary confinement on mental health can be particularly deleterious, especially for inmates who have serious mental illnesses such as schizophrenia or intellectual disabilities.  “While further research would be helpful, we know enough to be certain that solitary confinement is not good for your health.” The National Commission on Correctional Health Care recently issued a position statement with the attempt to limit the use of solitary confinement, and many organizations have joined in the call to reduce or eliminate these units all together. Some large correctional systems have begun changing practices and reduced the number of inmates in solitary confinement. “While improvements continue to be needed, many state correctional systems sharply limit the length of time an individual with serious mental illness can be placed in segregation/restrictive housing.”
Wilson furthers that the New York and Massachusetts Departments of Correction (DOC) were among the first to develop special treatment units to divert inmates with serious mental illness or behavioral disturbances from segregation or other restrictive housing.  The Pennsylvania DOC and other state correctional systems have followed suit.  These units provide both individualized and group treatment to address the inmate’s serious mental illness or behavioral disturbances and have proven to be very effective, even among inmates who engage in recurrent episodes of violence or self-injury. Other large systems, such as California, do not practice solitary confinement. Says Sessa, “We do house inmates in Administrative Segregation if they commit crimes within the prison, which means they are housed in a special wing that is more like a jail within the prison. They still have regular contact with custody officers, physicians, and mental health professions.”
Solitary confinement, Holmes recalled, had negative effects on inmates in the Minnesota jail in which he worked. In solitary, he says, there is nothing to stimulate the inmate’s brain. Everything is concrete, and stimuli are magnified. “The only thing you hear is yourself thinking.” Inmates begin to believe that their thoughts are actually voices. Upon being let out, the feelings carry over. Every noise is startling. Inmates become more isolated and tend to keep to themselves.
Early & Frequent Assessments
Best practices regarding detecting mental health issues, says Wilson, include “early and frequent assessment of inmates to ensure prompt detection of mental health needs, routine follow-up, additional mental health contacts during high risk, high stress situations, comprehensive suicide prevention training, and reduction of segregation and restrictive housing whenever possible all constitute best practices.”  Wilson, who is certified in mental health by the NCCHC, furthers that multidisciplinary collaboration in detecting and addressing mental health needs and suicide risk is essential and must include correctional, medical, case management, addictions treatment, and mental health staff.  “The need to provide treatment in confidential and private settings is so essential to mental health services that it has been compared to the need for antiseptic conditions to conduct surgery.”
At CDCR, says Sessa, “We provide every level of mental health treatment.” Among them are group and individual therapy. While working in the county jail, Holmes started a group program called Barbershop in which up to 50 inmates sat in a circle and talked about their lives, and what he found was striking. In many cases, the common thread among the inmates was that they had not been raised. That’s not to say they weren’t raised properly. Many hadn’t been raised at all. Inmates told him that he was literally the first person to ever tell them right from wrong. “They wanted to be heard. They wanted to purge it. That’s when the light went on. That’s why I want to go back to prison.” J