In July 2008, the Southern California ACLU released a "Report on Mental Health Issues at Los Angeles County" Jail by Dr. Terry Kupers, a practicing psychiatrist, an expert on long-term isolated prison confinement and correctional mental health issues. He's also written numerous articles on these topics, and been an expert witness on the mental health crisis behind bars, what he wrote about in his book "Prison Madness."
In May, he toured the LA County Jail system where most inmates aren't convicted and are awaiting trial - Men's Central Jail (MCJ), Twin Towers 1 & 2 (TT 1 & 2), and the Inmate Reception Center (IRC). He interviewed 18 prisoners in private, confidential settings; others in more casual, cell-front ones; and discussed issues with mental health and custody staff.
As in all prisons nationwide, many LA County inmates suffer "serious mental illness." Incarceration exacerbates it. They need treatment, but aren't getting it.
Besides prison confinement harm, state mental hospital deinstitutionalization took hold in the 1980s, part of Reagan Revolution policies that whatever government can do, business does better, so let it. As a result, large numbers of seriously ill patients were discharged, based on studies indicating community care was superior to state facilities. The consequences were predictable. The promise was never realized because of budget cuts, unaffordable housing, and other priorities.
In 1955, state and VA psychiatric hospitals had about 550,000 patients. In 2008, there were less than 60,000, but given constraints today on budget strapped states and communities, the numbers are likely lower and dropping.
Yet according to a study by the Federal Bureau of Justice Statistics, over a million individuals suffer from significant mental illness in jails and prisons. With 20,000 detainees, some call the LA County Jail system the largest psychiatric hospital in the country (the Men's Central Jail has 5,000), but, like elsewhere, treatment there's not forthcoming.
Correctional setting mental illness factors:
"are complex, including shortcomings in our public mental health systems, the tendency for post-Hinckley criminal courts to give relatively less weight to psychiatric testimony, the incarceration of large numbers of drug offenders including those with dual diagnoses (substance abuse and mental illness), and the growing tendency for local governments to incarcerate homeless people for a variety of minor crimes."
As a result, the prevalence of prison mental illness is high and rising - about 15 - 30% according to national epidemiological studies. The 2006 Special Report from the Federal Bureau of Prison Statistics titled, "Mental Health Problems of Prison and Jail Inmates," confirms a high, unprecedented mental illness population behind bars, concluding that 64% of jail inmates suffer significantly - based on structured interviews, "not necessarily clinical diagnoses."
A comparable 1999 study estimated 19%. The 2006 one concludes that previously homeless inmates are twice as likely to be ill, the result of living on streets or in unfavorable environments, unconducive to good mental health.
Other epidemiological studies concur with the Bureau of Justice Statistics, and despite the prevalence of inmate illness, few prisoners get help, what's provided is inadequate, and medications only for many are stressed. Even then, they're only given to symptomatic inmates, then withdrawn when they abate, when it's essential they be continued. Otherwise, those in need aren't helped.
Overcrowding and Few Inmate Programs - A Serious Problem
When the 1970s prison population was much smaller, studies showed overcrowding caused violence, mental illness, and suicides. Today it's much worse. "One ha(s) only to tour a jail or prison to understand how violence and madness were bred by the crowding."
Imagine a small dormitory expanded to house 150 prisoners - the situation in LA County Men's Central Jail with bunk beds lined up in rows. "A prisoner cannot move more than a few feet away from a neighbor, and lines form at the pay telephones and the urinals."
It's the same with four men crammed into small cells with barely enough room to get off bunks for any reason. The cells have no chairs, desks or any space but bunks to sit or lie on. It's enough to fray anyones nerves, but with "tough men" in small spaces, altercations follow, then disciplinary action, greater anger, and inevitable mental illness for many.
"In general, as an individual prone to psychosis becomes angrier, his thinking becomes more regressed and irrational, and therefore subjecting (these inmates) to conditions that exacerbate irritability and anger (worsens) their mental illness, often precipitating a state of acute decompensation or 'breakdown.' "
For those depression prone, self-imposed isolation to escape violence or unbearable conditions deepens their problem and "leads to thoughts of self-harm." Open rage and violence pushes some over the edge, especially with no remedial treatment. Also, mentally ill prisoners are prime targets for violence because they're vulnerabe. "The more violence, the more madness, and the crowding exacerbates both."
Over the past 30 years, few constructive changes were made in jail architecture. Most cells are windowless. Recreation for most is once a month. For many, none at all, even though they're supposed to have three times a week minimum. Even the Medical Disability/Stepdown area (6050) is deplorable.
"Men in wheelchairs, on crutches, and otherwise disabled were stuffed like sardines into long interconnecting, dark rooms with far too many bunk beds for them to be able to walk around." Absent are desks and chairs, and moving between bunks requires others to make way.
Under conditions of overcrowding and little rehabilitation, prisoners are idle - the result being worse traumas and abuse for many. Loners are especially vulnerable, an easy target for rapists or others to vent anger without retaliation.
Imagine a jail complex where 13,000 prisoners enter monthly in overcrowded quarters, others, of course, being released. But with inadequate assessments of mental illness and no treatment, inmates are on their own to survive in a very harsh environment. If they don't follow rules, they're in trouble, are punished, are abused by other prisoners, and their condition deteriorates.
"I was stunned by the degree of overcrowding I witnessed (on) May 8 & 9, 2008." Inmates stay in windowless cells nearly 24 hours a day, with no furnishings except their bunk. They have poor round-the-clock lighting. It disturbs sleep and hampers reading. They're noisy, fraying nerves. They eat there with no programs or mental health treatment possibilities. A combustible environment is inevitable, and it erupts daily.
In one Administrative Segregation Unit (2904), cells are also small (about 5 x 6 feet) with no windows and solid doors always closed. Isolation produces claustrophobia, suffering, and serious psychiatric harm.
"Throughout the Men's Central Jail (MCJ), the cells and dormitories violate minimum standards in terms of both social and spacial density (including) compensatory out-of-cell time for jail prisoners confined in substandard cells or dormitories. (It's) intolerable to leave prisoners in harsh, crowded conditions that we know cause psychiatric breakdown."
Conditions also affect staff. They get impatient, angry, and take it out on inmates for minor infractions. They, in turn react, and the longer they're incarcerated awaiting trial (at times years), the worse their condition becomes.
Like the MCJ, conditions in the Twin Towers are poor. Yet some positive mental health programs are in place, including inpatient beds in the Forensic Inpatient Program (FIP), crisis intervention/observation capabilities in TT 1, a step-down or subacute mental health unit, mental health housing, pre-release linking with community mental health services, and Jail Mental Evaluation Teams (JMET). The latter are "excellent in concept," but inadequate in implementation, prisoners outside mental health housing units saying they're not helped.
For the most part, little besides psychotropic medications are provided. Yet prisoners complain about not getting them or having them discontinued, their charts corroborating their accounts. Most inmates needing help wait weeks or months to be seen, that at best lasts a few minutes. Others are never seen because of too few staff to handle large numbers in need.
"I was told repeatedly by prisoners that there is nothing available in the way of mental health treatment except the prescription of psychiatric medications. This is far from adequate mental health treatment....There is a Pattern of Failure to Diagnose and Inappropriately Down-grad(e) the Diagnoses of Prisoners who Cannot be Accommodated in Mental Health Housing."
Some inmates are never diagnosed despite complaining of "significant psychiatric history." Others, seriously ill, are "un-diagnosed;" for example, Schizophrenia to a personality disorder, an "adjustment disorder," or "malingering." Without treatment, symptoms inevitably worsen, often jeopardizing inmate safety.
"It is important to note that serious mental illnesses are, mostly, lifetime conditions that pursue a waxing and waning course. An individual suffering from Schizophrenia might go into remission," especially if properly medicated, but it doesn't mean he's cured. Future eruptions can happen anytime and do. Under LA County Jail conditions, a complete breakdown or suicide can result.
"It is striking how indifferent mental health staff are to evidence of serious mental illness by history - past hospitalizations, Social Security Disability benefits, or even competency evaluations." Instead, they focus only on current symptoms, and do it poorly by misdiagnosing.
Disciplinary Housing Exacerbates Mental Illness and the Potential for Suicide
A "disproportionate number of prisoners with serious mental illness predictably wind up in punitive segregation." Besides harming them further, it contributes to a greater pandemonium level throughout the prison population because of their screaming and irrational actions like throwing feces at guards.
"Human beings require some degree of social interaction and productive activity to establish and sustain a sense of identity and to maintain a grasp on reality." Absent these, paranoia and an inability to control rage increases.
Segregated inmates do what they can. Some pace relentlessly. Others read and write letters, but many are illiterate. They fare worst in isolation. Anxiety, hallucinations, anger, obsessions, and/or despair result.
In isolation, previously healthy inmates develop psychiatric symptoms, including anxiety; rage; claustrophobia; panic attacks; headaches; lethargy; heart palpitations; violent fantasies; depression; and/or trouble focusing, remembering or sleeping.
Conditions "that cause emotional distress in relatively healthy prisoners cause psychotic breakdowns, severe affective disorders and suicide crises in prisoners who have histories of serious mental illness, as well as in (some) who never suffered a (previous) breakdown...."
Enough stress can break anyone, and "once an individual crosses a line into psychosis or depressive despair, it is very possible that (removing harsh isolation won't be able) to bring him back to a normal mental state."
Staff abuse is also a major problem. Based on widespread inmate reports, they're excessive, including severe beatings, compounded by the stress of overcrowding and inmate-on-inmate violence.
They're often made but ignored, including:
- reduce overcrowding;
- increase mental health treatment by competent staff;
- provide diversion for seriously ill prisoners;
- institute early release programs for outside treatment;
- address forced idleness, lack of recreation, and the need for more time out of cells - in day rooms, cafeterias, anywhere for needed relief;
- improve lighting and provide desks and chairs;
- remove mentally ill prisoners from overcrowded, toxic environments;
- create more housing for treatment and improved safety for the mentally ill;
- keep them out of segregation and disciplinary housing; they need mental health treatment in a proper setting;
- greatly expand mental health housing;
- halt harmful diagnosis down-gradings;
- properly evaluate psychiatric histories;
- improve JMET interventions and provide better outpatient services in the general prison population and other jail areas;
- provide a range of mental health services;
- have enough competent staff to serve needs;
- increase substance abuse treatment;
- provide more comprehensive post-release planning, including housing, medication, and other social services;
- increase staff training;
- take steps to reduce custodial abuse; and
- other remedial measures.
Whatever the cost, it's small compared to readmissions, a larger inmate population, and the toll on society when ill or abused prisoners return to communities.
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