Tam

Fionna Tam
ENG 123 KE
Prof. Morris
Spring 2016
Research Project

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Incarcerated individuals face many challenges that are often overlooked. These
individuals deal with issues both inside and outside the physical walls of prison and are in need
of mental health treatment and rehabilitation. Around 26% of the prison population is said to be
suffering from mental illness with little to no treatment (Gonzalez and Connell 2330). Due to the
lack of rehabilitative services in the United States, individuals with mental illness face higher
chances of recidivism (relapse into criminal behavior) than their counterparts. This creates a
situation where reintegration into their communities becomes difficult due to their mental
instability, thus placing them at a higher disadvantage than others. The solution of directing
resources towards mental health programs should be the priority, because it offers a more
comprehensive treatment plan than the solution of educational support. It is also the only
solution that can properly help the individuals suffering from mental illness. However, the
solution of educational support does offer help for the general incarcerated population, while
mental health programs do not. Both are plausible solutions to the issue, but mental health
programs will take priority over the solution of educational support due to the need in identifying
and treating the underlying cause of an incarcerated individuals behaviors.
A speculated reason as to why mental health is an issue for correctional facilities is
because they lack the proper funding for mental health intervention and treatment (Gonzalez and
Connell 2328). Another reason could be that mental health treatments are not taken seriously
because the prison systems place greater importance on physical health over mental health, or
that improper diagnosis provides easier facilitation of inmates. Individuals that have been
diagnosed with a mental disorder had a 70% chance of being incarcerated again (Gonzalez and
Connell 2328). A study completed in 2004 of 18,185 prisoners by the Survey of Inmates in
Federal Correctional Facilities concluded that 26% of inmates had been diagnosed with a mental

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health condition and only 18% of those diagnosed were being treated pharmaceutically for their
condition (Gonzalez and Connell 2329-2330). It can be seen that a lack of continuity in treatment
is partially at fault for the increase of the prison population. The incarceration rate is likely to
continue to grow if proper treatment programs for these affected individuals are not made
available. This issue impacts the prisoners and individuals within the prison system, but also
impacts the surrounding outside communities.
Incarceration rates are also a concern for communities since they are at risk for negative
mental health development, as examined by researchers Mark L. Hatzenbuehler, PhD, Katherine
Keyes, PhD, Ava Hamilton, MS, Monica Uddin, PhD, and Sandro Galea, MD, DrPH
(Hatzenbuehler et al. 138). Members of the communities were identified to also have certain
mental health conditions like major depressive disorder and generalized anxiety disorders. This
could be due to concern of safety and negative occurrences in the community like theft and
robbery. The mentioned types of mental illnesses are highly correlated to the risk of violent and
dangerous behaviors (Hatzenbuehler et al. 142). It is no wonder that individuals with mental
illness and incarnation history had a 70% chance of being incarcerated again (Gonzalez and
Connell 2328). The link between mental illness and violence raises the chances of incarceration
in a community, which then leads back into the cycle of mental illness and recidivism. The cycle
itself brings to question how this issue first began.
In the 1950s, the United States were faced with an ever-growing problem, however
instead of inmates, it was the growing number of inpatients in psychiatric wards (Raphael and
Stoll 188). The mental health care system was being stretched thin and the government was
desperately seeking a solution. Eventually, through a series of key events, they settled on

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deinstitutionalization. This type of solution would then lead to a new, unforeseen problem shortly
thereafter, the overcrowding of prisons.
Before deinstitutionalization in the 1950s, the psychiatric inpatient rate was three times
that of the incarceration rate (Raphael and Stoll 188). Many of those individuals suffering from
mental illness were housed in state and county psychiatric institutions. Treatments in those
facilities included electroconvulsive therapy, insulin coma therapy, and lobotomy, which
included significant side effects like brain damage. These side effects were common and required
indefinite support and facilitation (Harcourt 65). This attributed to the growing rate of inpatients,
as there was never a real cure. Patients that went into the psychiatric wards rarely came out. It
wasnt until 1954 when the first psychiatric medicine was created that patients were able to leave
the facilities. Originally created to sedate surgical patients, this new medicine and its
tranquilizing effects were able to provide pharmaceutical treatment for mental illness. The drug
chlorpromazine, also known as Thorazine, was prescribed to over 2 million patients by 1956
(Harcourt 65). It was able to help facilities manage care even with the overpopulation of
inpatients. The usage of this new psychiatric drug eventually led it to a bigger purpose in the
United States.
The United States government saw this newly developed treatment as a solution for the
growing inpatient rate. This led to the Community Mental Health Centers Act, which was
instated by President John F. Kennedy in 1963. This act created community based mental health
facilities, allowing institutionalized patients to become outpatients (Harcourt 65-66). Essentially,
this act would change funding from state to the federal government (Harcourt 67). After
implementation of the act, the systematic releasing of inpatients back into their communities
began. The act was aimed to drop inpatient population by 50%, but instead resulted in a 75%

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drop, which was observed from 1955 to 1980 (Harcourt 54). In 1965, Medicaid and Medicare
also gave incentive for states to move inpatients to federal subsidized facilities like psychiatric
wards of hospitals and nursing homes (Harcourt 67). Medicaid and Medicare didnt payout to
institutions that centered on treatment for mental illnesses because they were state controlled and
federal programs (Medicaid and Medicare) only paid out to federal controlled facilities.
Supplemental Security Income or also known as SSI, was another incentive for patients to
become outpatients because it provided income for food, clothing and shelter (Harcourt 67).
However, government intervention isnt the only driving force for change, it also comes from the
public.
In 1946, Life Magazine published an article that revealed the disturbing treatment of
mentally ill patients (Harcourt 69). Other magazines followed suit and the trend to publicize
these types of issues continued as a hot topic in the media. This eventually led to books and
movies in the late 1960s that depicted the abuse and horrors of being institutionalized. The
public perception on the mentally ill began to change with this newfound insight and caused
public out-cries for change. Institutionalization was now seen as a violation of human rights
instead of a means for treatment and laws began to change as a result. In 1975, the U.S Supreme
Courts decision on the case of OConner v. Donaldson caused many states to change their
involuntary-commitment laws, which made the act of involuntary commitment more challenging
to carry out (Raphael and Stoll 191). The Fifth Circuit in Wyatt v. Stickney case in 1972 enforced
standard of care for patients and guaranteed their constitutional rights even while committed
(Harcourt 71). The backlash at psychiatric facilities resulted in the continued decline of the
inpatient population. As the inpatient population fell, the prison population began to rise. It was
observed that individuals with mental health issues had a higher rate of committing violent

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crimes than others (Raphael and Stoll 191). In more recent times, an estimated 40,000 to 72,000
inmates with severe mental health issues should have been inpatients at a mental hospital
(Raphael and Stoll 219). The public speculated that psychiatric facilities were ill equipped to
treat individuals with mental illness, however prisons are even more ill equipped.
Prisons werent built to properly treat and facilitate the mentally ill. This pertains to the
mentally ill because of the correlated risks of violent and dangerous behavior, which in turn put
them at risk for incarceration (Hatzenbuehler et al. 142). In prison, individuals with mental
health issues had higher chances of being placed in solitary confinement than other inmates. It
was speculated that those with mental health issues had difficulties following facility rules, thus
the reason for their solitary confinement (Cloud et al. 22). Solitary confinement as a
rehabilitative punishment started in the United States more than 200 years ago and in present
times has increased 40% in only a single decade (Cloud et al. 18-19). Prolonged isolation drove
most inmates to insanity (Cloud et al. 19). Solitary confinement created a situation that further
harmed these types of individuals due to their mental instability. With the releasing of patients
from psychiatric institutions without careful planning of treatment, most of them have
unfortunately ended up in prison to suffer such fates like solitary confinement.
Deinstitutionalization started off as a means to end the issue of overcrowding in
psychiatric facilities, but now the United States is left with the issue of repeat offenders which
just so happen to have mental disorders. Even though unintentional, the mentally ill have been
transferred over to another ill equipped facility instead of being properly treated, which
otherwise is also known as trans-institutionalization. The public believed that the crisis of
treatment and abuse in psychiatric institutions have been solved with the releasing of the
patients, but the mentally ill still face the same difficulties with improper treatment in prisons.

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The solution would be to provide correct mental health treatment and care if the United States is
to avoid repeating the past of trans-institutionalizing its population of the mentally ill again.
Currently, both the criminal justice and mental health community are debating policy
solutions to the problem of mental health and recidivism due to the ever-rising rate of
incarceration. The main policies that are being argued for include directing resources towards
more educational help and resources towards mental health programs. These solutions both offer
help to inmates and seek to lower recidivism. However, when resources are limited, only one
solution will be given the chance to make a difference.
Scholars like Greg A. Greenberg, and Robert A. Rosenheck argue for resources towards
educational help (Greenberg and Rosenheck 29-30). In order to come to their proposed solution,
they have studied the correlations between mental illness history and incarceration records. In
past studies, there have been correlations from data surveyed by the prison population instead of
national population surveys on mental illness. However, Greenberg and Rosenheck wanted to
determine how the results differ between sources. By working with the United States
Government for their study, they gathered data from 2001 to 2003 from the National
Comorbidity Survey Replication (Greenberg and Rosenheck 18). The scholars measured
information such as gender, education, marital status, language, race, ethnicity, and other
socioeconomic characteristics. Common factors they found to be associated with the history of
incarceration include: single, male, of the poorer socioeconomic class, little education,
homelessness, trauma as an adult, all mental health diagnosis (excluding agoraphobia) and
substance abuse (Greenberg and Rosenheck 26). They also found that anxiety, mood, and
impulse disorders did not have a strong connection to incarceration odds (Greenberg and
Rosenheck 29). Out of all other factors, people who experienced homelessness had a higher

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chance of being incarcerated than anyone else (Greenberg and Rosenheck 30). Instead of
focusing on mental health, Greenberg and Rosenheck proposed that resources should be directed
towards more educational opportunities to combat homelessness, thus reducing recidivism in
both individuals of mental issues and non-sufferers (Greenberg and Rosenheck 29-30). An
example of an education program are the green prison programs, which teach inmates a
vocational skill set in gardening and landscaping. In turn, inmates also develop social skills,
teambuilding, and mindfulness during their education. This program lowered recidivism by 10%
to 24% (van der Linden 338). An admirable solution to combat recidivism and incarceration
rates, however this solution is a fix for the general prison population and doesnt address specific
treatment needs.
Mental health specialty programs can address the treatment needs of the incarcerated
population. The solution of directing resources toward mental health programs provides
availability to individuals inside and outside the prison systems. According to Scholars David C.
Kondrat, William S. Rowe, and Melanie Sosinski, different programs in the United States help
inmates with severe mental health problems. They evaluated transition planning and the Forensic
Assertive Community Treatment program, otherwise known as FACT in the United States
(Kondrat et al. 101). Currently in fourteen states, transition planning arranges community
services for inmates with mental illness there before release from prison. This program requires
prison personnel to work together with community mental health personnel to plan for the
appropriate services the inmate will need outside of prison. The plan is comprehensive and
individualized. Transition from Prison to Community or also known as TPC, is an example of
transition planning (Kondrat et al. 102). The FACT program involves a team of providers,
psychiatrists, social workers, nurses and specialists who work together with individuals suffering

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from mental illness. There are sixteen programs in nine states currently using this program. In
conclusion, FACT and transition planning were observed to lower recidivism significantly
(Kondrat et al. 102).
Another mental health program is the Step-Down Unit program (Kuper et al 1042). This
program was first developed and carried out for the Unit 32 incident at Mississippi State
Penitentiary by Terry A. Kupers, MD, MSP, Theresa Dronet, PhD, Margaret Winter, James
Austin, PhD, Lawrence Kelly, William Cartier, PhD, Timothy J. Morris, Stephen F. Hanlon,
Emmitt L. Sparkman, Parveen Kumar, MD, Leonard C. Vincent, Jim Norris, Kim Nagel, MD,
and Jennifer McBride (Kupers et al 1050). The Step-Down Unit was an intermediate-level
treatment program for inmates with severe mental illnesses. It involves a tier of cells that are
divided into segregated cells and open-population cells. During the program, inmates started off
in segregated cells when they had displayed positive behavior, they were relocated to openpopulation cells. The inmates received treatment in each tier and were also educated on coping
mechanisms. In addition, group therapy was also available when inmates had displayed positive
behavior when interacting with others. The staff overseeing the program were mental health
providers and security personnel to ensure there was quality of care for each inmate (Kupers et al
1043). In the end, recidivism was not observed during the study of Unit 32, but serious
misconduct and incidents had dropped by 70% (Kupers et al 1043).
Nevertheless, having comprehensive and individualized planning and treatment does
offer more help for the mentally ill, but it comes at a higher cost than education. This expense for
medication and treatment from mental health personnel can be observed as costly.
Comparatively, an educational faculty team can be more economic than a larger team of mental
health providers. Unlike mental health programs, education can teach and provide inmates with

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the tools to pursue a career, thus enabling them to be at a better financial state. In the case of
green prison programs, education was seen to be cost effective and helped inmates cope and
relieve stress (Van der Linden 430), however its not enough to treat persons with severe mental
illness. Even with a better start and career opportunities, improperly treated or untreated mentally
illnesses will still remain a threat to the individuals. Eventually, these individuals will need the
educational help. Therefore, mental treatment takes priority to ensure they are mentally and
behaviorally prepared to receive educational help. The comprehensiveness of the mental health
programs can effectively treat the array of mental illnesses that inmates can suffer from. Overall,
comprehensiveness and priority needs to come before cost, therefore, mental health treatment
would be the solution. A delay in treatment may have negative repercussions on the individuals
mental health in addition to negatively impacting the United States prison systems.
From the overcrowded psychiatric institutions of the past to the overcrowded prisons
today, little has changed in regards to the treatment of the mentally ill. Methods of treatment may
have changed, but suffering is still present. Each facility can only offer so much help when
resources are limited. To tackle this issue, more mental health programs inside and outside the
prison systems are needed. This is the call to action. Scripture calls to action through the
following: Then the King will say to those on his right, Come, you who are blessed by my
Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I
was hungry and you gave me something to eat, I was thirsty and you gave me something to
drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick
and you looked after me, I was in prison and you came to visit me. Then the righteous will
answer him, Lord, when did we see you hungry and feed you, or thirsty and give you something
to drink? When did we see you a stranger and invite you in, or needing clothes and clothe you?

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When did we see you sick or in prison and go to visit you? The King will reply, Truly I tell you,
whatever you did for one of the least of these brothers and sisters of mine, you did for me (NIV,
Matthew 25.34-40). What we do for the mentally ill suffering in prison, we do for God. The
simple act of voting and familiarizing ones self with policies can greatly help the cause and help
those in need. After all, it was the public outcries for change that helped the mentally ill escape
the abuse in psychiatric institutions so many years ago. It can be done yet again to help them
escape the cycle of recidivism and mental illness once and for all.

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Works Cited
Ackerman, Jenn. Trapped. Digital Image. Jenn Ackerman. Trapped: Mental Illness in Americas
Prisons. 10 July 2009. prisonphotoggraphy.org. 8 February 2016
"BibleGateway." Matthew 25:34-40 NIV. N.p., n.d. Web. 8 Feb. 2016.
Cloud, David H., et al. "Public Health And Solitary Confinement In The United States."
American Journal Of Public Health 105.1 (2015): 18-26. Academic Search Premier. Web.
14 Jan. 2016.
Doctor Attacked by Inmate at Mule Creek State Prison. Digital Image. Fox40. 13 August 2013.
Fox40.com. 8 February 2016
Gonzalez, Jennifer M. Reingle, and Nadine M. Connell. "Mental Health Of Prisoners:
Identifying Barriers To Mental Health Treatment And Medication Continuity." American
Journal Of Public Health 104.12 (2014): 2328-2333. Academic Search Premier. Web. 26
Jan. 2016.
Greenberg, Greg A., and Robert A. Rosenheck. "Psychiatric Correlates Of Past Incarceration In
The National Co-Morbidity Study Replication." Criminal Behaviour & Mental Health
24.1 (2014): 18-35. Academic Search Premier. Web. 26 Jan. 2016.
Harcourt, Bernard E. "Reducing Mass Incarceration: Lessons From The Deinstitutionalization Of
Mental Hospitals In The 1960S." Ohio State Journal Of Criminal Law 9.1 (2011): 5388.Criminal Justice Abstracts. Web. 26 Jan. 2016.
Hatzenbuehler, Mark L., et al. "The Collateral Damage Of Mass Incarceration: Risk Of
Psychiatric Morbidity Among Nonincarcerated Residents Of High-Incarceration

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Neighborhoods." American Journal Of Public Health 105.1 (2015): 138-143. Academic
Search Premier. Web. 12 Jan. 2016.
Kondrat, David C., William S. Rowe, and Melanie Sosinski. "An Exploration Of Specialty
Programs For Inmates With Severe Mental Illness: The United States And The United
Kingdom." Best Practice In Mental Health 8.2 (2012): 99-108. Academic Search
Premier. Web. 26 Jan. 2016.
Kupers, Terry A., et al. "Beyond Supermax Administrative Segregation: MississippiS
Experience Rethinking Prison Classification And Creating Alternative Mental Health
Programs." Criminal Justice And Behavior 36.10 (2009): 1037-1050. PsycINFO. Web. 2
Feb. 2016.
Miller, Caleb Bryant. Digital Image. Solitary Confinement Study Approved but Lacks Funding.
14 January 2014. Kut.org. 8 February 2016
Raphael, Steven, and Michael A. Stoll. "Assessing The Contribution Of The
Deinstitutionalization Of The Mentally Ill To Growth In The U.S. Incarceration Rate."
Journal Of Legal Studies (0047-2530) 42.1 (2013): 187-222. Criminal Justice Abstracts.
Web. 26 Jan. 2016.
Shock Therapy. Digital Image. Restoring Perspective.
https://www.lib.uwo.ca/archives/virtualexhibits/londonasylum/shock.html. 8 February
2016
Van der Linden, Sander. "Green Prison Programmes, Recidivism And Mental Health: A Primer."
Criminal Behaviour & Mental Health 25.5 (2015): 338-342 5p. CINAHL Complete. Web.

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2 Feb. 2016.