CENTER FOR PUBLIC REPRESENTATION
246 Walnut Street Mental Health Protection & Advocacy
Project
Newton, MA 02460
617/965-0776
617/964-6560 (TTY)
617/928-0971 (FAX)
February 1, 1999
THE LEGAL RIGHTS OF PRISONERS WITH MENTAL DISORDERS
There are at least 1.8 million people
incarcerated in prisons or jails in the United States, and the number continues
to increase each year. The incidence of mental disorders among prisoners is
substantially higher than it is in the community, with approximately ten
percent of prisoners suffering from a major mental illness, defined as
schizophrenia, bipolar disorder, or major depression. Indeed, the Los Angeles
County Jail has been called the largest de facto mental hospital in
the world. Additionally, at least 1-2% of all inmates have a developmental
disability.
Despite the tremendous demand for
mental health treatment, the available services in many, if not most, prisons
and jails are woefully inadequate. In the words of Stuart Grassian, a Harvard
Medical School psychiatrist who has served as an expert witness in many prison
mental health cases, "I've seen people who are horribly ill, eating their
own feces, eating parts of their body, howling day and night and it's ignored,
like 'who cares?' You think it belongs to some other century, but you go into
the prison and you think you're back in some medieval torture chamber. The
prison has become this place that's hidden and secret and it's really
awful." Given the lack of resources available to treat prisoners with
mental illness, it is not surprising that the suicide rate in prisons and jails
is much higher than in the community as a whole. Nor is suicide the only risk.
Prisoners with untreated mental illness are also vulnerable to victimization by
other inmates, may pose a threat of assault to correctional officers and staff,
and can seriously disrupt the prison routine. They are also likely to face
discrimination in classification, access to rehabilitative programs, and
parole.
Constitutional Principles
Since there is little public or
political support for quality mental health care for offenders with mental
illness, prisoners have been almost entirely dependent on the courts for
protection of their right to treatment. Dozens of class action law suits have successfully
attacked the overall quality of care in correctional institutions across the
country. See e.g., Coleman v. Wilson, 912 F.Supp. 1282 (E.D. Cal.
1995); Austin v. Pennsylvania Dept. of Corrections, 876 F. Supp.. 1437
(E.D. Pa. 1995); Dunn v. Voinovich, Case No. C1-93-0166 (S.D. Ohio
1995); Madrid v. Gomez, 889 F. Supp. 1146, 1280 (N.D. Calif. 1995); Langley
v. Coughlin, 715 F.Supp. 522 (S.D.N.Y. 1989), aff'd 888 F.2d 252
(2d Cir. 1989).
The starting point for an understanding
of the constitutional principles underlying the claim of inmates to mental
health services is Estelle v. Gamble, 429 U.S. 97 (1996), where the
Supreme Court held that the Eighth Amendment's prohibition against cruel and
unusual punishment endows all inmates with a right to medical care.
Specifically, the court ruled that prison officials may not exhibit
"deliberate indifference" to the "serious medical needs" of
inmates. Thus, an Eighth Amendment claim has two basic elements: an objective
component, the existence of a "serious medical need"; and a
subjective, or state-of-mind, component, namely that a prison official was
"deliberately indifferent" to the need for treatment. The cases
elaborating the constitutional requirements in this area, however, are often murky
and inconsistent. For example, courts have considerable difficulty in deciding
what mental health needs are "serious" enough to mandate treatment. Compare
Steele v. Shah, 87 F.3d 1266, 1267 (11th Cir. 1996) (prisoner who
"suffered from insomnia, anxiety, and various bodily pains" and
"feelings of helplessness" stated a claim under the Eighth Amendment)
with Doty v. County of Lassen, 37 F.3d 540 (9th Cir. 1994)
(female prisoner who experienced nausea, shakes, headache, sleeplessness, and
depressed appetite suffered merely from "mild, stress-related
ailments" and "routine discomfort" did not have a
"serious" medical need). Generally, however, prisoners have a right
to psychological or psychiatric treatment under the Eighth Amendment if a physician
or other health care provider "concludes with reasonable medical certainty
(1) that the prisoner's symptoms evidence a serious disease or injury; (2) that
such disease or injury is curable or may be substantially alleviated; and (3)
that the potential for harm to the prisoner by reason of delay or the denial of
care would be substantial." Bowring v. Godwin, 551 F.2d 44 (4th
Cir. 1977). Thus, mild depression and anxiety associated with the stress of the
prison experience will not be regarded as a "serious," while any
condition that is diagnosed by a doctor as mandating treatment must receive
professional attention.
Discerning whether or not prison
officials have demonstrated the requisite "deliberate indifference"
can be similarly confusing. It is not enough that prison officials exercised
poor judgment, or that they were negligent or even grossly negligent; rather
the inmate must show that the prison official was at least reckless, and
reckless in the criminal sense, meaning that he or she had actual knowledge of
a condition that required treatment. Farmer v. Brennan, 511 U.S. 825,
828-829 (1994). This does not mean that prison officials may shield themselves
from liability by deliberately remaining ignorant about the need for treatment.
They will still be held accountable if they deliberately disregard a known
risk, even if they are ignorant of the details of a particular inmate's
situation.
Basic Components of a Prison
Mental Health System
While there may be controversy about
whether a specific inmate has received constitutionally acceptable care, the
courts have established a clear set of minimum requirements for an adequate
system of prison mental health care. Further, a number of professional
organizations, such as the National Commission on Correctional Health Care and
the American Psychiatric Association, have promulgated standards governing
mental health services in prisons and jails. See e.g., National Comm'n
on Correctional Health Care, Standards for Health Services in Prisons
(1997). Although courts are fond of saying that the professional standards may
well exceed the constitutional floor, they often utilize such standards, both
to evaluate the quality of mental health care and to devise remedies for
conditions found to be unlawful.
The essential components of a prison
mental health system are set forth below. For a more detailed account,
including citations to professional standards and cases, consult the Summary of
Professional Standards Governing Mental Health Services in Prisons and Jails
published by ATTAC in 1998.
1. Screening and Evaluations
The first requirement is that every
inmate be screened upon admission in order to identify those with mental
illness or developmental disabilities. This generally entails a standardized
set of questions and observations by specially trained staff. The screenings
must be conducted in a confidential setting. There must be a mechanism to
ensure that all inmates identified as possibly suffering from a mental disorder
are promptly referred for a comprehensive mental health evaluation and any
necessary treatment. The threshold for referral for services must be low, both
upon admission and later, since it is easy for mentally ill inmates to escape
notice in the prison environment so long as they do not engage in egregiously
bizarre behavior. In addition, inmates must be monitored throughout their
incarceration in the event they develop signs and symptoms of mental illness.
It is crucial that inmates who are in segregation or solitary confinement be
assessed by mental health staff at least once per week. It is also vital that
the institution have a program to identify and supervise suicidal inmates and
those in crisis.
2. Treatment Modalities
Correctional institutions must provide
a range of meaningful treatment modalities to inmates identified as having a
mental disorder. Although many prisons and jails simply confine mentally ill
inmates to segregation units where they can be closely supervised, this is not
acceptable. The institution must make available psychotropic medication if
needed. Psychotropic medication must be prescribed only by a psychiatrist and
in accordance with contemporary medical standards. Psychiatrists or physicians
should monitor all inmates on psychotropic medications and re-evaluate the
patient before renewing the prescription. Further, the prison formulary should
contain a range of psychotropic medications.
Medication alone, however, is not
sufficient. It must be part of an overall program of therapy, including
individual and group therapy where appropriate, as well as crisis intervention
services. Each inmate with a chronic mental disorder should also have an
individualized treatment plan. In addition, the facility must provide qualified
interpreters to ensure that non-English speaking inmates have access to mental
health services. Further, no inmate with a history of mental illness should be
disciplined without first consulting with mental health staff.
3. Qualified Mental Health Staff
It is absolutely essential that the
institution have sufficient numbers of qualified and trained staff to provide
treatment consistent with contemporary standards of care. This means the
facility must have an adequate number of psychiatrists, psychologists, and
other mental health professionals, either on site or on call, to provide all necessary
services. Although there are no clear standards quantifying an appropriate
number of mental health professionals, experts generally insist that the
caseload of a prison psychiatrist should be no more than 125-150, and jail
psychiatrists should not have a caseload that exceeds 75-100. One of the worst
consequences of inadequate staffing is that only those mentally ill prisoners
who exhibit especially bizarre behavior, or who are assaultive and disruptive,
are likely to receive any treatment at all. Even though their illness may be
equally severe, those who suffer quietly go unnoticed and unserved. This
problem is exacerbated by the common failure to provide sufficient training to
correctional officers concerning the signs and symptoms of mental illness.
4. Special Needs Units and
Inpatient Hospitalization
Like individuals suffering from mental
illness in the community, inmates may sometimes need special housing separate
from the general prison population to receive more intensive treatment and
supervision. This may range from a day treatment program within the prison, to
a crisis unit for acutely psychotic or suicidal inmates who does not require
inpatient hospitalization, to an intermediate level residential treatment unit
for those whose level of functioning makes them vulnerable to abuse from other
inmates, are too disruptive for placement in the general population, or who
need substantial therapeutic services. Since sometimes nothing short of
intensive inpatient hospitalization is adequate for an inmate who has
decompensated, the institution must also have a procedure to transfer acutely
mentally ill prisoners to a hospital setting.
5. Accurate Mental Health Records
Mental health treatment records must be
accurate, complete, up-to-date, and well-organized. The facility should also
obtain past psychiatric records whenever possible. The inmate's mental health
records must be kept confidential by maintaining them
separately from other records. When an
inmate is transferred to another institution, his records must be sent to the
receiving facility to insure continuity of care.
6. Discharge Planning
Since most mentally ill inmates are
eventually released back to their communities, it is vital that the facility
make an effort to ensure continuity of care after release. This may mean
providing the inmate with a medication prescription, as well as arranging for
follow-up services in community mental health centers.
7. Quality Assurance Program
The institution must have a quality
assurance plan to assure that inmates receive competent care. This should
include studies of utilization patterns and clinical outcomes in the facility
as a whole, as well as analysis of the clinical record of individual prisoners.
Although many prisons and jails have
carefully drafted policies and procedures designed to meet their constitutional
obligations regarding mental health care, there is often a wide gulf between
what exists on paper and the services that are actually available. The quality
of the services and the physical plant is also often substandard. Thus, there
is no substitute for thorough factual investigation in order to make an
assessment of the adequacy of the mental health services in any jail or prison.