Before attempting to understand how the standard of mental health care is tied to larger issues within the prison system, it is important to establish how mental health care is insufficient in a broad sense. When looking at the rates of mental illness within the incarcerated population, it becomes clear that a strong system of mental health care is absolutely vital. As of 2014, 73% of women and 55% of men in state prisons, 61% of women and 44% of men in federal prisons, and 75% of women and 63% of men in local jails had at least one mental health problem (James and Glaze, 2019). This is not simply an issue of lack of initiative in seeking mental health care on the part of individuals with mental illness, as “even psychiatric patients who are actively being treated often get tangled up in the criminal justice system: in 2012, researchers reported that 12 percent of adult psychiatric patients receiving treatment in the San Diego county health system had been incarcerated; in 2013, 28 percent of Connecticut residents being treated for schizophrenia and bipolar disorder had been arrested or detained” (Varney, 2019). This data clearly shows that not only are a large majority of inmates mentally ill, but an unfortunate number of individuals with mental illnesses will end up in the prison system.
The Bureau of Justice Statistics, a government agency focused on reporting statistical analyses about the justice system, compiled data from 45 states who responded to surveys about the conditions of health care in their facilities. An important consideration to make before presenting the data is that it was gathered at the state level, and therefore, may obscure variability within states. Despite that caveat, the data offers a solid initial look at the processes of psychiatric care within prisons. In regards to mental health screenings, every state reported that they offer screenings to “at least some prisoners during the admissions process”, which raises the question of which prisoners are and are not being screened (BJS, 4). The data was further broken down to say that one state provided mental health screening only as needed and based on whether a prisoner had a history of mental health issues. Of the thirty-one states who offered information about who is responsible for screenings in their facility, psychologists and psychiatrists were only responsible in seven of these states. The majority had either some other form of licensed mental health care provider (including master’s-level social workers) or nurses. Having less than qualified individuals administering the screenings runs the risk of losing the nuance that psychiatrists and psychologists are trained to observe in mental illness diagnoses. Screenings for suicide risk had the same results: at least some prisoners were screened (Chari et al., 4). Offering screenings on a discretionary basis is a major cause for concern, considering there is a significantly higher number of individuals with mental illnesses in prisons compared to mental health hospitals. Furthermore, the primacy of this screening process suggests that it is the first step towards receiving care, and if it is only administered to some, those who do not receive it are initially barred from access to care. Given the importance of treating mental health issues as quickly as possible, this can be a dangerous oversight.
In contrast with the high numbers of incarcerated individuals with mental health issues, the Bureau of Prisons classified only 3% of the prison population as requiring routine care for mental illness. This comes as a direct result of policy changes intended to shore up the quality of mental health care in these institutions. Unfortunately, but unsurprisingly, the change in care demanded was not accompanied by any further resources to do so. In response, many institutions began treating fewer individuals instead. In combination with the issues seen in the screening process, there is clearly reason to believe that many, if not most, of the incarcerated individuals who would benefit from receiving mental health treatment are not receiving it.
Given that people of color are more likely to be in the prison system due to systemic profiling, it is important to consider how mental health care needs and the actuality of treatment received may differ for inmates of color compared to white inmates. In 2016, “Black people were 2.17 times more likely to be arrested, 3.5 times more likely to be incarcerated in jail, and nearly five times more likely to be incarcerated in prison nationwide than white people” (Prins et al., 2012). One primary issue, both in and out of prison, is the issue of receiving a diagnosis in the first place. Black prisoners were, as of 2017 data, 20% less likely to receive a mental disorder diagnosis. White, non-Hispanic prisoners were also 26% more likely to be diagnosed than Hispanic inmates. The root of this disparity can be found in the methods of diagnosis. Recalling the BJS data that reported mental health screenings were administered on a discretionary basis, there is a risk that the discretion could fall, with or without intention, along racial lines. Furthermore, the actual screening process has its flaws. A study conducted by Seth J. Prins, Fred C. Osher, Henry J. Steadman, Pamela Clark Robbins, and Brian Case attempted to assess the generalizability of the Brief Jail Mental Health Screening. They found that the lower likelihood of black and Latino inmates screening positively could be linked to the fact that “Blacks and Latinos had somewhat lower odds than Whites of endorsing two or more symptom items but had appreciably lower odds of endorsing items regarding prior mental health service utilization” (Prins et al., 2012). The biased idea that everyone has equal access to mental health services ignores the role of class and the overlap of class and race in previous mental health care access.
Along the same lines, sexual minorities are not only incarcerated at higher rates disproportionate to the percentage of the population that they make up, but once incarcerated, they are more likely to experience mistreatment, harsh punishment, and sexual victimization. Additionally, sexual minority inmates were more likely to have a past history of sexual abuse. Higher rates of sexual victimization are linked with worsening mental health, as seen in the application of the diathesis-stress model for most serious mental illnesses.
Roughly 17% of transgender Americans, and 50% of black transgender people, have been imprisoned. The issues transgender people face are many in the prison system. They risk being incorrectly housed with the wrong gender, or as a dangerous alternative, being placed in solitary to avoid housing them with either group. Additionally, they are often denied hormones and adequate treatment. Both of these issues feed into worsening mental health. Beyond the logistical failings of transgender people in prisons, they have to worry about their safety, as well: “Trans women's degree of satisfaction with their body is associated with mental health outcomes...Transphobia-based violence was significantly associated with anxiety, depression, and body satisfaction. Body satisfaction was associated with mental health diagnoses. Bootstrapping revealed significant indirect and total effects. Body satisfaction mediated the relationship between transphobia-based violence and mental health. Clinical intervention that promotes body satisfaction, including access to gender confirmation therapies, especially hormone therapy, may prevent negative mental health outcomes among trans women. Individual intervention, however, is not a panacea for structural discrimination. Attention to structural interventions that reduce gender minority stressors, including transphobia-based violence is necessary” (Klemmer et al., 2018).
The role of capitalism and the prison-industrial complex in the failure of mental health care in prisons is extensive. Overcrowding reduces the chance of all inmates who need mental health care receiving adequate treatment. As previously mentioned, stricter regulations around the quality of care were not accompanied by the funds necessary to extend that higher quality care to the entire prison population. For this reason, there is reluctance on the part of prisons to offer care to anyone they do not absolutely have to. This restricts care to only those most visible, and based on issues with screening, the most visible population will most likely be white. Not only does overcrowding place restrictions on care, but it also negatively impacts mental health.
Intentional lack of adequate mental health care in prison has more than one positive capitalistic outcome: it saves them money when the inmate is still imprisoned and allows them to make more money when the inmate eventually returns after being released. Mentally ill inmates have been found to have higher recidivism rates. The issue of recidivism is tightly connected to the issue of homelessness after release. Many inmates, particularly those who are members of minority populations, and especially those who are mentally ill members of those populations, struggle with finding a home and a job after being released. Adding the search for health care to that list puts an undue burden on mentally ill ex-inmates and increases their likelihood of recidivism in the long run. In regards to homelessness broadly, “formerly incarcerated people are nearly 10 times more likely to be homeless, and rates of homelessness are especially high among people of color. Lack of housing can significantly worsen mental health problems” (Prins et al., 2012).
While an understanding of the current conditions in prisons, both broadly and specifically in regard to mental health care, shows a clear need for change, it is not as simple as mild adjustments. It comes down to the question of whether to reform the current system or abolish it and build something new from the ground up. As Fran Beale discusses in ‘Double Jeopardy: To Be Black and Female’, the work we do cannot simply be about highlighting the issues we see in the old, “a revolutionary has the responsibility...of creating new institutions that will eliminate all forms of oppression” (Beale, 100). With reform, only so much can be done. When rebuilding with a rotten foundation, there will always be some level of corruption. The advantage to prison abolition is removing ourselves entirely from that system and opening the door for something more fruitful, and most importantly, more just in a way that considers Patricia Williams’ distinction between what is legal and what is just. She defined legality as the word of the law, without any of the emotions, whereas justice requires subjectivity. In her own words, “When a society loses sight of those ideals and grants obeisance to words alone law becomes sterile and formalistic; lex is applied without jus and is therefore unjust” (Williams, 1991, pp.138-139). Our current system is, as she says, all lex and no jus.
Works Cited
Beale, Frances. 'Double Jeopardy: To Be Black and Female'. The Black Woman: An Anthology, edited by Toni Cade Bambara, 1970, pp. 90–100.
Chari, Karishma et al. 'Bureau of Justice Statistics (BJS) - National Survey of Prison Health Care: Selected Findings'. Bjs.Gov, 2019, http://www.bjs.gov/index.cfm?ty=pbdetail&iid=5705
James, Doris, and Lauren Glaze. 'Bureau of Justice Statistics (BJS) - Mental Health Problems of Prison and Jail Inmates'. Bjs.Gov, 2019, http://www.bjs.gov/index.cfm?ty=pbdetail&iid=789
Klemmer, Cary L., et al. 'Transphobia-Based Violence, Depression, and Anxiety in Transgender Women: The Role of Body Satisfaction'. Journal of Interpersonal Violence, Mar. 2018, doi:10.1177/0886260518760015.
Prins, Seth J. et al. 'Exploring Racial Disparities in the Brief Jail Mental Health Screen'. Criminal Justice and Behavior, vol. 39,5 (2012): 635-645. doi:10.1177/0093854811435776.
'Protected and Served?'. Lambda Legal, 2019, https://www.lambdalegal.org/protected-and-served/jails-and-prisons
Thompson, Christie, and Taylor Eldridge. 'Why so Few Federal Prisoners Get the Mental Health Care They Need'. The Marshall Project, 2019, https://www.themarshallproject.org/2018/11/21/treatment-denied-the-mental-health-crisis-in-federal-prisons
United States Government Accountability Office. FEDERAL PRISONS: Information on Inmates with Serious Mental Illness and Strategies to Reduce Recidivism. 2018, https://www.gao.gov/assets/700/690090.pdf Accessed 14 Dec 2019.
Varney, Sarah. 'By the Numbers: Mental Illness Behind Bars'. PBS Newshour, 2019, https://www.pbs.org/newshour/health/numbers-mental-illness-behind-bars
Williams, Patricia. The Alchemy of Race and Rights. Harvard University Press, 1991.