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Report on State Prisons Cites Inmates' Mental Illness

New York Times, October 21, 2003

Nearly 1 of every 4 New York State prisoners who are kept in punitive segregation - confined to a small cell at least 23 hours a day - are mentally ill, according to a new report by a nonprofit group that has been critical of state prison policies.

1 in 5 of the roughly 5,000 prisoners punished with that isolation have a serious drug problem, the report said. But despite graphic evidence that the most acutely ill prisoners in punitive segregation, or lockdown, often grow only more troubled and violent, the state Department of Correctional Services, which runs the state's 70 prisons, rarely does anything to help them, said the report, released yesterday by the group, the Correctional Association of New York.

To the contrary, when inmates in punitive segregation try to hurt or kill themselves, the department's policy is to punish them with additional lockdown time, according to the report. About 1/2 of the 258 inmates interviewed by the report's authors said they had attempted suicide in prison. Many prisoners spend years under lockdown.

The findings of the association, an inmate-advocacy group, are based on state records, the authors' visits to 29 state prison lockdown units and interviews with hundreds of prisoners, correction officers and prison supervisors. The association, established in 1844, is authorized by state law to visit prisons and interview inmates and employees.

The Correctional Services commissioner, Glenn S. Goord, declined to comment yesterday on the report's specific conclusions and recommendations, which include changing prison rules so that emotion ally disturbed inmates who misbehave would be treated instead of sent to isolation. Instead, Mr. Goord accused the Correctional Association of proffering "phony issues," and criticized the report's principal author, Jennifer Wynn, as unprofessional.

But in interviews, several prison experts, psychiatrists and state officials who are familiar with the report agreed with its conclusion that the prison system is unprepared to properly treat mentally and physically ill inmates.

Yesterday, an independent report by Human Rights Watch found that as many as 25 % of prisoners nationwide are mentally ill.

"The 25 % is very much like it is for other states; there are probably some that are even worse, and it's a scandal," said Michael L. Perlin, a professor at New York Law School who has studied prison mental health issues. "It reflects a mentality that we should have discarded a century ago."

Professor Perlin, who sits on the Correctional Association's advisory board, said Commissioner Goord, who has dismissed criticism of punitive segregation in the past, should heed the association's findings. "There should be a tremendous obligation on the part of New York's authorities to deal with this frontally and forthrightly," he said.

In the association's 51-page report, the authors paint a grim portrait of the lockdown units in some state prisons. They describe observing one inmate alone in his cell, smeared with his own feces; another inmate sprawled on the floor because his wheelchair was confiscated for security reasons; a prisoner with AIDS, dying and barely able to lift his head; and dozens of others with symptoms of acute psychoses or covered in scars from self-inflicted cuts.

"These are serious human-rights abuses," said Robert Gangi, the Correction Association's executive director. "There are people who die needlessly in New York State prisons because they are put in there when they are mentally ill, and they kill themselves."

He added, "The state's political leaders should recognize how important a matter this is."

Using nearly $200 million in federal grants, New York has built 10 prisons with 3,788 beds since 1997, solely for punitive segregation, Mr. Gangi said. Beyond those units, there are more than 20 "segregated housing units" in the state's seven maximum security prisons, as well as lockdown cells in separate blocks within other prisons.

About 7.6 % of the 65,000 inmates in the state prison system were in lockdown in April, according to the report.

The report said department records indicate that the average prisoner in 23-hour lockdown remains there for 5 to 6 months before returning to the general prison population. (One hour a day is allowed for what is called recreation in a small, empty outdoor cage.) But in interviews with inmates, the association reported their average stay to be three years. Most punitive segregation is solitary confinement; some units house 2 inmates.

In an interview in May 2000 in DOCS Today, a departmental newsletter, Commissioner Goord said segregated housing units "had an immediate and positive effect on the system" by reducing inmate assaults on correction officers.

But Dr. Stuart Grassian, a psychiatrist who has studied the effects of isolation on mentally ill inmates, said that when dealing with mentally ill and drug-addled inmates, what is good for the prison system is not good for public safety.

"The paradigm is that if we punish them enough, they will change their behavior," Dr. Grassian, whose research is cited in the report, said yesterday.

"There's too great a tendency to label their behavior as willful. You put them in situations that are more and more stressful, their behavior will become worse."

He added, "Most of these people get out at some point, and then they become a danger to all of us."

Despite repeated cases of inmates hanging and starving themselves while in punitive segregation, and despite repeated criticism from the State Commission of Correction, an oversight agency with little authority to force the department to change its rules, New York prisons are not much different from those in many other states.

"This is an issue for every prison system," said Michael P. Jacobson, a former New York City correction commissioner who is a professor at the John Jay College of Criminal Justice.

Punitive segregation costs less per prisoner than less restrictive prison blocks because it requires fewer officers and relatively less space for programs and activities. In its report, the Correctional Association accused the department of sending too many inmates into punitive isolation for infractions like smoking cigarettes or "horseplay."

Mr. Jacobson said, "You have to be very selective about who goes in" lockdown cells, "and you have to be very careful about watching them once they're in."

In its report, the Correctional Association recommended creating an oversight body with authority to inspect lockdown units, a body similar, in fact, to the Board of Correction, which sets minimum standards for inmate populations in New York City jails and monitors them.

After receiving an advance copy of the Correctional Association's report, in August, Mr. Goord, the Correctional Services commissioner, accused Ms. Wynn, the report's principal author, of using the Correctional Association's privileged status to communicate with a particular inmate, and he banned her from entering the prisons beyond the visiting area. Since then, he has imposed new limits on how many association employees may visit a prison, prohibited association interviews with prison staff and declared access to all segregated housing units off limits.

Jeffrion L. Aubry, a Democratic state assemblyman from Queens and chairman of the Committee on Corrections, said he plans to introduce a bill in January that would prohibit inmates with serious mental illnesses from being sent to lockdown and require them to receive treatment instead.

"I've been in the S.H.U.'s," he said, recalling how he was temporarily locked in a segregated housing unit during a tour of a state prison. "I'm not surprised they have a negative impact on inmates."

Out of the Asylum, Into the Cell

New York Times, November 1, 2003

A new report by Human Rights Watch has found that American prisons and jails contain three times more mentally ill people than do our psychiatric hospitals. The study confirmed what mental health and corrections experts have long known: incarceration has become the nation's default mental health treatment. And while the report offers good suggestions on how to help those who are incarcerated, a bigger question is what we can do to keep them from ending up behind bars at all.

The Los Angeles County jail, with 3,400 mentally ill prisoners, functions as the largest psychiatric inpatient institution in the United States. New York's Rikers Island, with 3,000 mentally ill inmates, is second. According to the Justice Department, roughly 16 percent of American inmates have serious psychiatric illnesses like schizophrenia, manic-depressive illness and disabling depression.

Life on the inside is a special nightmare for these inmates. They are targets of cruel manipulation and of physical and sexual abuse. Bizarre behavior, like responding to imaginary voices or self-mutilation, can get them punished - and the usual penalty, solitary confinement, only worsens hallucinations and delusions.

How did we get here? Actually, with the best of intentions.

Forty years ago yesterday, President John F. Kennedy signed the Community Mental Health Centers Act, under which large state hospitals for the mentally ill would give way to small community clinics. He said of the law that the "reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability."

Kennedy was acting in response to a genuine shift in attitudes toward the mentally ill during the postwar years. The public and lawmakers had become aware of the dreadful conditions in the state hospitals, largely though exposes like Albert Deutsch's book "The Shame of the States" and popular entertainment like the movie "The Snake Pit," both of which appeared in 1948. In addition, Thorazine, an anti-psychotic medication, became available in the mid-50's and rendered many patients calm enough for discharge.

Between Kennedy's signing of the mental health law in 1963 and its expiration in 1980, the number of patients in state mental hospitals dropped by about 70 %. But asylum reform had a series of unintended consequences. The nation's 700 or so community mental health centers could not handle the huge numbers of fragile patients who had been released after spending months or years in the large institutions.

There were not enough psychiatrists and health workers willing to roll up their sleeves and take on these tough cases. Closely supervised treatment, community-supported housing and rehabilitation were given short shrift. In addition, civil liberties law gained momentum in the 70's and made it unreasonably hard for judges to commit patients who relapsed but refused care. Those discharged from state hospitals were often caught in a revolving door, quickly failing in the community and going back to the institution. And they were the lucky ones - many others ended up living in flop-houses, on the streets or, as Human Rights Watch has reminded us, in prison.

Reforms like segregating mentally ill prisoners in treatment units would help. Of course, the ultimate solution is keeping psychotic people whose criminal infractions are a product of their sickness out of jails in the 1st place.

This requires a two-part approach. The first entails repairing a terribly fragmented mental health care system. The most important change would be liberating states from the straitjacket of federal regulations surrounding the use of money from Medicaid and Medicare - programs that account for 2/3 of every public dollar spent on the mentally ill.

These regulations force many states to make rigid rules dictating what services will and won't be reimbursed, which forces practitioners and administrators to perform bureaucratic gymnastics to circumvent them. For example, Medicaid will not pay for clinicians who provide "assertive community treatment" - a system in which professionals work as a team, making home visits, checking on medication and helping patients with practical day-to-day demands. Yet such teams have been proved to reduce re-hospitalization rates by up to 80 %.

Relaxing regulations would be great progress in helping those mentally ill people who seek treatment. Unfortunately, about half of all untreated people with psychotic illness do not recognize that there is anything wrong with them.

Thus the 2nd part of any sensible reform would be finding ways to help patients who have a consistent pattern of rejecting voluntary care, going off medication, spiraling into self-destruction or becoming a danger to others.

One approach is encouraging their cooperation with "treatment through leverage." This process, not new but underused, involves making social welfare benefits, like subsidized housing and Social Security disability benefits, conditional to participation in treatment.

A more formal approach is to have civil courts order people to enter community treatment. New York State's Kendra's Law, named in memory of a woman killed in 1999 after being pushed into the path of a subway train by a man with schizophrenia, is a good model. From 1999 to 2002, about 2,400 people spent at least 6 months in mandatory community treatment under the law.

And for those who end up committing crimes, some states have developed special mental-health courts that can use the threat of jail to keep minor offenders with psychosis in treatment and on medication at least long enough for the offenders to make informed decisions about treatment. Such efforts may get help from Washington: last Monday the Senate approved a bill authorizing $200 million for states to develop more mental-health courts and other services for nonviolent, mentally ill offenders; it awaits action in the House.

For many thousands of mentally ill people, America has failed to make good on John F. Kennedy's promise of 40 years ago. Releasing them from the large state institutions was only a first step. Now we must do what we can to free them from the "cold mercy" that comes with criminalizing mental illness.

(source: Opinion, Sally Satel, a psychiatrist and a fellow at the American Enterprise Institute, is co-author of the forthcoming "One Nation Under Therapy.")
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