The recent 2014 Joint Report of the Treatment Advocacy Center and the National Sheriffs’ Association1 could have been a most useful and timely report on the critical issue in correctional mental health today: the woefully inadequate access to appropriate levels of mental health services for the enormous and growing number of seriously mentally ill persons in jails and prisons. Instead, it is a tendentious monograph that will add to the worsening root of the problem, precipitously eliminating hospital treatment for severely mentally ill inmates.
The purpose of the study was to conduct the first national survey of treatment practices for mentally ill persons in prisons and jails, with a focus on treatment-refusing, seriously mentally ill inmates. Among the sheriffs and administrators interviewed, there was consensus on 3 points:
• The number of mentally ill in jails and prisons continues to climb, and the severity of their mental disorders is worsening
• Jail and prison officers “feel compelled to provide the hospital-level care that these inmates need”1(p6)
• “The root cause of the problem is the continuing closure of state psychiatric hospitals and the failure of mental health officials to provide appropriate aftercare for the released”1(p6)
The implication is that the reduction of hospital and other mental health services for civilians has led to an increasing number of seriously mentally ill persons who end up behind bars. This public policy, which led to trans-institutionalization, is a big part of the root of the problem—the tap-root, as it were.
Unfortunately, there was no consensus about the increasing withdrawal of hospital services from seriously mentally ill inmates. The withdrawal of hospital mental health services from mentally ill inmates should have been concerning. Sheriffs and jail administrators may be able to do little about the reduction of services that leads to more mentally disordered persons being incarcerated. However, they can be concerned about and attempt to address the other side of this issue: the withdrawal of hospital services for individuals for whose care they are responsible. Because of the way it was designed and carried out as well as the way the data were organized and presented, rather than addressing the root cause, the survey promoted the practice/policy of introducing and supporting enforced medication in correctional settings and ignored the possibility of making hospital care available to inmates in need of this level of care.
This bias toward providing involuntary medication in jails and prisons rather than addressing the root cause is evident not only in the opening paragraph of the Joint Report, but also in the survey itself and in the concluding recommendations. The survey summary for each of a num-ber of states begins with the com-ment, “State law does not prohibit [the state’s] county jails from administering medication involuntarily on a nonemergency basis. Therefore, county jails could use a Washington v Harper administrative proceeding to authorize involuntary medication for an inmate who is suffering from a mental disorder, is gravely disabled, or poses a likelihood of serious harm to self or others.”1(p32) The paragraph concludes with the observation that the mechanisms in place for hospitalization or enforced medication are not used much, if at all, or are not working.
Of the 6 recommendations to address the treatment needs of the seriously mentally ill in jails and prisons, none supports an increase in the number of available beds for seriously mentally ill patients in need of hospital-level treatment. Neither is a recommendation made for measures to expedite hospital transfer. Hospitalization of inmates with mental disorders was entirely overlooked as a potential solution to the unavailability of hospital care.
The first recommendation, foreseen in the Joint Report’s introductory paragraph as well as in how the data were obtained and presented, was: “Provide appropriate treatment for prison and jail inmates with serious mental illness.” Even within the discussion of this recommendation, hospitalization is not mentioned for the seriously and acutely mentally ill, who, were they not incarcerated, would most certainly be hospitalized. Instead, legislation is proposed to allow involuntary medication, and a “model law” patterned after the Washington v Harper2 decision is included in the appendix.
Dr Felthous is Professor and Director in the forensic psychiatry division, department of neurology and psychiatry at the Saint Louis University School of Medicine in Saint Louis. He reports no conflicts of interest concerning the subject matter of this article.
1. Torrey EF, Zdanowicz MT, Kennard AD, et al. The treatment of persons with mental illness in prisons and jails: a state survey. A Joint Report of the Treatment Advocacy Center and the National Sheriffs’ Association; April 8, 2014. http://tacreports.org/storage/documents/treatment-behind-bars/treatment-.... Accessed July 16, 2014.
2. Washington v Harper, 494 US 210 (1990).
3. Felthous AR. The Ninth Circuit’s Loughner decision neglected medically appropriate treatment. J Am Acad Psychiatry Law. 2013;41:105-113.
4. American Medical Association. Code of Medical Ethics. Chicago: American Medical Association Press; 2002.