State of Mental Health in Corrections

By now it’s common knowledge that correctional facilities have become the housing unit for millions of people with mental health issues. The statistic often mentioned is that for every person in a state mental facility, there are 10 in jails and prisons. Some people with serious mental health conditions are often convicted of minor crimes and end up in an environment with little or no treatment. Some have even been detained without any formal charges.

In California alone the numbers are staggering. “Currently, says Bill Sessa, information officer at the California Department of Corrections and Rehabilitation, “about 38,000 inmates [approximately one-third of its population] receive some form of mental health treatment. The overwhelming majority (about 75%) receive basic care that includes medications and counseling. About 6,000 receive a slightly higher level of care as outpatients, meaning that they see medical/clinical staff regularly but are still housed in the general population. The remaining five percent receive care for what you would consider the most severe illnesses, including inpatient care where they are housed in a hospital-like setting.” (The CDCR’s budget for mental health services alone last year was $396.6 million.)

John Wilson, Ph.D., CCHP-MH, vice president of Clinical Development at MHM Services explains, “The most prevalent mental health issues experienced by incarcerated individuals include substance use disorders, mood disorders, psychotic disorders, and trauma related disorders.” He furthers that despite the data that the number of incarcerated individuals has been decreasing, the number with mental health issues appears to be rising. (Three quarters of respondents in a survey of county jails remarked that they have seen an increase in severely mentally ill inmates.) This places more stress on an already strained mental health departments in correctional facilities. Joel Andrade, director of Clinical Operations—Mental Health at MHM Services, points out, “Correctional departments have been forced to develop innovative ways of providing mental health treatment to this population.”

A July 2016 Research Report from the Public Citizen’s Health Research Group and The Treatment Advocacy Center called Individuals with Serious Mental Illnesses in County Jails: A Survey of Jail Staff’s Perspectives compiled data from a total of 230 county jails operated by sheriffs’ departments. Jails and prisons face different tasks and obstacles. For one, county jails house a variety of inmates who have not been sentenced. According to Magnus Lofstrom and Brandon Martin’s fact sheet “California’s County Jails,” nearly two-thirds of inmates are awaiting arraignment, trial, or sentencing.  Compounded with the facts that these jails are not designed for providing mental health treatment, and employees are not generally trained to provide it, the question remains, Who has the primary responsibility for coordinating mental health treatment in correctional facilities and how should it be done?

Wilson notes that there are many challenges to the provision of mental health care in corrections.  In fact, the Report Serious Mental Illnesses in County Jails found that only 1.7% of respondents noted that patients with a serious mental illness (SMI) did not present special problems. Inmates with SMI, the report found, require extra supervision, are more likely to disrupt normal jail activities, and are more likely to abuse and to be abused.
Despite the fact that the standards for correctional mental health care have increased over the past few decades, challenges persist. Not only are there fiscal limitations to correctional budgets that limit the number of staff that can be hired, there is a national shortage of mental health professionals, including psychiatric providers.
Correctional facilities were not designed for providing mental health care, and many have limited space in which to conduct treatment. There is also a shortage of correctional officers, which has an impact on inmates’ access to care.  Inmates arriving in jails usually arrive without a medical history available, and prior treatment records can be difficult to obtain, in which case mental health providers must “start from scratch.”

Staffing Issues
Furthermore, says Wilson, staff are subject to what is known as “vicarious traumatization,” or exposure to trauma through the provision of treatment.  “Many patients inside jails and prisons have experienced horrific events.”  While mental health staff are cautious not to “dig into the past” in the context of a challenging treatment environment, these stories nevertheless come out and can have a negative impact even in seasoned professionals. “Retention of staff is a significant challenge, as there is a great demand for mental health staff in the community and staff may perceive community settings as more desirable practice environments.” On top of all of those, inmates might be leery of trusting mental health staff. “All of these challenges must be addressed carefully by mental health staff in the context of ensuring safety for the patient and staff.”
One other issue that is not well-recognized within corrections is the fact that most inmates who suffer from SMI have at least one, and very often two or three, chronic medical conditions.  “There is a significant line of research showing that the ‘excess mortality and morbidity’ associated with serious mental illness—the amount of early death and increased disease associated with serious mental illness—is due to these co-occurring medical conditions.  Coordination of care for both physical and mental health is critical,” Wilson says.

The County Jails Report found that certain concerns among the employees of county jails are that “With the current judicial system and the lack of mental health facilities these [seriously mentally ill] inmates are getting ‘stuck’ in the system.” Other concerns are that many mentally ill inmates come into the system having committed minor infractions such as trespassing, and then they get caught up in the slow system and end up being housed much longer than normal. Most of the seriously ill inmates are also under court order to be held (without charges) until a state bed opens, and that wait is getting longer and longer.
As Wilson says, “Inmates with mental health issues require the same kind of care, attention, understanding, and interventions that are required for patients with mental health issues in the community.”  The nature of conditions such as depression or psychosis does not change just because the symptoms are manifesting inside a prison instead of a clinic or hospital, and incarceration often adds stress, which can exacerbate symptoms. Incarceration also increases the level of complexity of the required interventions.  
Inmates often come from “highly under-privileged backgrounds and have experienced significant deprivation and trauma. Impulsivity, anger, violence, and self-injury are frequent, and most inmates with serious mental illness also have co-occurring substance use disorders.” Wilson furthers, “We know less about effective treatments for inmates with mental health issues than we would like. Research is limited, and it is not ethical to place inmates on waiting lists or placebo treatments. They have no other options for treatment than the mental health staff who provide services.  Our best bet is to use cognitive-behavioral and psychopharmacological interventions that are consistent with community standards of care.”

Ike Randolph, director of Communications at Indiana Department of Correction (IDOC) stresses that “there is no ‘magical’ treatment that they can say is most effective in treating mental illness.”  Many variables have to be considered and ultimately will influence what works best for individuals. “We try to offer as many different kinds of treatments that include groups, individual, psychoeducational, medication, milieu, etc.”

Limited Community Resources

Wilson says, “Inmates being released to the community often have few options for continuing care.” Most Departments of Correction do not follow-up with inmates once they have been released.  Mental health staff who work in prisons and jails work hard to align incarcerated mental health patients with community resources prior to their release, but there are significant challenges, including limited community resources.  “Continuity of care at release remains one of the biggest challenges in the care of correctional mental health patients.”  He furthers that service delivery systems need to “talk” to each other regarding care passed from correctional to community mental health organizations.
One effort that has found success is considering what happens to inmates upon release. As a result of the Affordable Care Act (ACA), inmates are more likely to enter society with medical insurance, which all Americans are mandated to have. Previous to the ACA, often an inmate would be supplied with a month’s worth of medications and be re-incarcerated shortly after. Now that having medical insurance is mandated, inmates can continue services once back in the community. The process, though, can be a difficult one to navigate. Says Sessa on the matter, “One of the reasons we worked so hard to get inmates on Medicare or Medi-Cal before they are released is so that they can have their medical prescriptions covered as they leave the prison. That prevents lapses in medication.”
IDOC also has a system in place for inmates upon release. Offenders are monitored while on parole, and there are social workers now assigned to all parole offices “who assist parole agents in following up on mentally ill offenders and their aftercare.”

On November 8, the Republicans took the White House and both Chambers of Congress. Among the reasons was the vehemently repeated promise to repeal the ACA. The potential repeal may cause concern among the correctional community. Bill Sessa of CDCR says, “I think this question may be premature since we don’t know what changes are in store, but generally it will not affect our inmate health care. None of that is funded by the ACA. All of it comes from our budget and the state’s general tax dollars. We do have an aggressive program to get soon-to-be-released inmates signed up for Medicare so that when they leave prison, they are equipped with the meds they need and are prepared if they need further medical help once they are released.  But again, like everybody else, we don’t have any idea what, if any, specific changes will be made to Medicare, so for now we are only as concerned as everyone else in the country waiting to see if things will change in that regard.”
The State of Indiana, Randolph notes, created its own version of ACA called HIP 2.0, and as long that can stay funded, “actions on the ACA should not affect us.”  If HIP 2.0 changes, though, “then we will return to the time when offenders leave prison with no insurance, which greatly affects their ability to get follow-up care.”
MHM is an outsourced medical provider, and among the myriad services they offer is aligning inmates with Medicaid and access to subsequent care upon release. Regarding the concern about the potential repeal, Wilson says, “Yes, definitely. The outcome of any repeal will be determined by the scope and nature of ACA’s replacement. Correctional systems will be monitoring this situation closely so that staff can respond quickly to new requirements, new systems, and changes in community resource availability. Whatever the form of replacement legislation, health equity needs to be the goal if the underserved patient populations are to receive adequate access to mental health resources. Inmates with mental illness did not ask for or create their own illnesses. They need treatment.”