It’s not uncommon to hear that there are large numbers of severely mentally ill persons in correctional institutions around the country. In fact, some publications boldly claim that jails and prisons are the new psychiatric institutions due to their extraordinarily high numbers of mentally ill. The American Psychiatric Association, for instance, estimates that approximately 22% of state prison inmates suffer from either Schizophrenia, Major Depressive Disorder or Bipolar Disorder (1). The Treatment and Advocacy Center’s estimates are similar, suggesting that around 20% of jail inmates and 15% of state prison inmates have serious mental illnesses – numbers they consider conservative (2). The National Alliance on Mental Illness (NAMI) says that 15% of men and 30% of women in jails are mentally ill (3). In the National Institute of Corrections publication, “The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey,” the authors go even further to say that the number of incarcerated individuals suffering from major mental illness exceeds the number of patients in American psychiatric hospitals.
These statistics and allegations are head-turning if not downright shocking, especially when we consider that most of those mental illnesses have prevalence rates around 1 or 2% in the general population. However, those allegations and statistics are poorly substantiated, overstated and largely untrue.
First and foremost, it is vitally important to understand that there is absolutely no doubt that mental illness exists inside of correctional facilities. There are, unquestionably, severely mentally ill people who are languishing in jails and prisons, receiving inadequate treatment and would likely be better served in another setting. As I have written about previously (Mental Illness in the Legal System), the long term results of deinstitutionalization played a major role in assuring that too many severely mentally ill individuals ended up homeless or incarcerated. In addition to this unfortunate policy and its many negative consequences, there are other legal factors that contribute to the mentally ill inmate population. For example, the legal threshold to consider a defendant competent to stand trial is very low, which means that a person who suffers from a mental illness may be actively ill, yet still competent in the eyes of law; thus, they are able to be prosecuted, convicted and sentenced to incarceration (read more about competence here). Similarly, the insanity defense is rarely invoked and most frequently unsuccessful. By extension, this may mean that some legitimately mentally ill defendants who did not successfully achieve an insanity verdict end up in prison (read more about insanity here).
Although there are truly mentally ill people in jails and prisons for these and other reasons, the statistics and allegations that are widely publicized are exaggerated and based upon fatally flawed data.
Mislabeling in a Flawed System
The common approach to determining if an incarcerated individual has a mental illness is customarily conducted by someone with little or no training in recognizing mental illness. Most often, this person is armed with a quick and superficial assessment where they are required check boxes. This screening process is intended to get a “snapshot” of the inmate’s legal, medical, and mental health history, as well as other factors. Based upon the answers they provide during the screening, they are categorized based upon perceived level of need. If they declare a major mental illness, they are likely to be categorized as having one or at least referred for additional evaluation. Once they are categorized, they will receive routine contact with mental health staff to check in because they are seen as higher need, at risk, etc. Very few incarcerated inmates will receive a comprehensive evaluation from a qualified mental health professional that would result in a confident determination of whether they actually meet the diagnostic criteria for a mental illness.
Given that many inmates come from rough backgrounds, abuse substances and have longstanding behavioral problems, their allegations, at times, can sound like mental illness. They may report volatile moods, behavioral disturbances, troubled relationships, sleeping and eating disruptions and even hallucinations or delusions. However, these problems can also result from a variety of causes that are not mental illness. A quality evaluation is needed to determine if these allegations are indeed true, and if so, why they occurred. For example, were they using drugs when the hallucinations occurred? Was law-breaking behavior or their incarceration the cause of their relationship problems? Were their behavioral problems due to lifelong antisocial tendencies?
If the inmate had psychiatric treatment in the past, acquiring records may be challenging, if they are sought at all. Thus, in many situations, the psychiatrist or psychologist may have to make a determination based on only self-reported information from the inmate. As a result, they often end up with a diagnosis and taking psychiatric medications for a variety of reasons, yet without quality, objective information to know if they are truly mentally ill. Even if they do not acquire a formal diagnosis, the categorization they received during the initial screening will stay with them.
Although admittedly a bit of a glib conclusion, it takes little more than a self-declaration for an inmate to be designated mentally ill while incarcerated. Furthermore, changing or undoing the designation once it has been assigned is uncommon, meaning that anytime an inmate returns to prison, they will be presumed mentally ill based on their historical category from the previous incarceration.
The conclusion is that many inmates are officially counted in formal statistics as mentally ill based upon this flawed process.
Given the structures of processing and categorizing inmates, it should be unsurprising that the data the aforementioned claims and statistics are based on is significantly flawed. As noted above, it is infrequent that an inmate receives a comprehensive evaluation from a mental health professional who is qualified to render diagnoses. Thus, when we look at the official statistics, we do not see a valid representation of verified, bonafide mentally ill individuals. Instead, we are seeing information that is largely derived from inmate self-reports in a short, superficial and incomplete evaluation process. For example, in the 2017 Bureau of Justice Statistics report, “…14 percent of state and federal prisoners and 26 percent of jail inmates reported experiences that met the threshold for serious psychological distress…” (emphasis added). That same report goes on to plainly state the indicators for the origin of the data: “self-reported experiences that met the threshold for SPD in the 30 days prior to the survey and having been told at any time in the past by a mental health professional that they had a mental health disorder.”
The first half of the statement illustrates a broad swath of potentially inaccurate information based solely on what an inmate says they have experienced. The second part of the statement represents another troubling possibility that will be discussed more below.
The 2007 BJS report was even more shocking, noting that more than 50% of all inmates had a mental health problem, which they very broadly defined as “a recent history or symptoms of a mental health problem.” In addition to the type of data used, the methods of what/who was included vs. excluded and the modes of collection are often also troubling and raise serious questions about the reliability of the data used.
While self-report data is not inherently bad and should not be callously dismissed, it must be considered and interpreted very cautiously as well as used alongside of objective and professional observation and collateral information. Healthcare patients from every discipline, not just mental health, misunderstand, misinterpret and misstate their problems routinely. For example, simply telling a physician you think you have cancer is not likely to result in a diagnosis and recommendation for chemotherapy. The physician will do thorough assessments, which will include both self-reported and objective data to arrive at a final diagnosis. Professional assessment and testing are common and required to distill patient self-reports into usable data that can lead to the best chance of an accurate diagnosis.
Extra diligence in assessment is needed with mental illness because there are no formal tests to confirm diagnoses. Furthermore, and unfortunately, inmates have many reasons to deceive and manipulate and many do it very well and very often, including using false or misleading allegations of mental illness to their own ends.
The Reliability of Community Diagnosis
Even in those cases where inmates’ self-reports are honest about having been given a diagnosis by a mental health professional in the community, there is still good reason to be skeptical. Objective observation and professional assessment and judgment by the correctional mental health staff are still needed in those cases. Overdiagnosis and misdiagnosis are rampant in American mental healthcare, as I discussed extensively in The Dangers of Misdiagnosing Mental Illness and touched upon in other articles. This is partly due to many diagnoses being given by medical professionals with inadequate training in mental health issues (e.g. primary care doctors, OB/GYNs), but they are not entirely to blame. Well-meaning mental health professionals assign inaccurate diagnoses for many reasons, including pressure from insurance companies, employers or patients themselves, poor understanding of diagnostic criteria, personal/professional agendas, lack of experience, incompetence and others.
In addition, inmates disproportionately suffer from substance abuse disorders and antisocial behaviors, which can masquerade as or confuse a mental health condition. Sadly, many mental health professionals, both in the community and in correctional institutions do a poor job of accounting for the role of substance use prior to rendering a major mental illness diagnosis. Similarly, they may see the anger, moodiness, and poor self-control of Antisocial Personality Disorder as due to a mental illness. As all competent clinicians know, the diagnosis of a psychiatric condition must include an assessment and determination that the symptoms/behaviors are not better accounted for by another disorder. For substance abuse, a substantive period of sobriety is required to establish a confident baseline of functioning before any additional diagnoses can be considered. Unsurprisingly, a large majority of inmates come to jail or prison with a longstanding substance abuse problem; very often, their mental health diagnosis was given during a time of known use, rendering said diagnosis invalid.
Consider this simple and sadly common scenario:
Bob has been abusing heroin for 15 years. One day, he overdoses and ends up in a hospital emergency room. After he is revived, he is angry and agitated and threatens to kill himself. He goes to a psychiatric ward, where he gives a 15 year history of rage episodes and other mood dysregulation, as well as reckless and dangerous behavior. He is diagnosed with Bipolar Disorder and discharged after 3 days with some prescriptions. He never fills the prescriptions and returns to using heroin. A few years later he is arrested for robbery and incarcerated. During the routine jail screening, he endorses mental health problems hoping to get out of jail; he tells the nurse he has a diagnosis of Bipolar Disorder. He is given the requisite ranking and referred to the psychiatrist. Upon checking records, they find his story to be “true;” he was diagnosed with Bipolar Disorder. He is now part of the official statistics: majorly mentally ill and incarcerated even though there is no justifiable evidence he has a mental illness.
Jails and prisons may have a disproportionate number of people with diagnostic labels, but they have immensely fewer mentally ill people.
Why does this matter?
For hundreds, if not thousands of years, the mentally ill have been stigmatized and discriminated against in nearly every way imaginable. In recent decades, there seems to be a trend of massive overreach in which acquiring a diagnosis of mental illness is far easier and more common. Diagnostic categories are broader, vaguer and more abundant and providers are generously assigning them. One of the end results is that more people than ever are now considered mentally ill (depending on the study, the numbers suggest 25-50% of the general population at any given time).
This overreaching is not going to fix age-old stigma and discrimination against mentally ill people, nor will it normalize the presence of mental illness in society. It only mislabels people and dilutes true mental illness.
That same overreach is now being used to allege that jails and prisons are warehouses for the mentally ill. With copious diagnoses being handed out by unqualified professionals to patients who are insufficiently vetted, it’s not surprising that some American systems are seemingly overrun with “mental illness.” Corrections is not immune from this impact. Reckless diagnosis and poorly constructed data have created the illusion of a crisis. Although the intent may have been to curb stigma and discrimination, the opposite is occurring.
Perhaps the biggest detriment of this false crisis is that it diverts scarce resources away from those who truly need it. As long as mental health problems have been recognized, sufferers have struggled to get quality help; deinstitutionalization obliterated what little there already was. The reckless proliferation of illegitimate mental illness as outlined above is only making it harder for actually mentally ill people – in prison and not – to find, access and use the few resources there are. This is nothing new to them, however. Throughout human history, they have been shuffled to the back of the line. Today, they are in line behind inmates with unsubstantiated labels.
It also perpetuates the chronic problem of misdiagnosis. If someone gets a diagnosis while in prison, they will carry that into the community where it may be prolonged, along with unneeded or inappropriate treatments, which also diverts resources from others. Furthermore, it misinforms the inmate of their own condition, potentially giving them an excuse for their reckless behavior or subjecting them to unnecessary and inappropriate interventions. Similarly, it creates and reinforces damaging misperceptions. For example, one particularly troubling misperception is that the mentally ill are dangerous. By inaccurately pairing together incarcerated inmates with severe mental illness, we are reinforcing the widespread, false belief that mentally ill people are dangerous. Telling the public that our prisons are overrun with them only fuels this false belief.
Another misperception is that the mentally ill are being mistreated by the criminal justice system and locked up when they really should be in hospitals or other treatment centers. This can be destructive because these desperately flawed statistics are being used by advocacy groups, politicians and others to drive issues like criminal justice and/or mental health reforms. While discussions to improve these broken systems are desperately needed, doing so based on false data will damage credibility, lead to poor and non-working changes and other bad outcomes.
It should go without saying that we should always strive for reliability, validity and the utmost ethical standards in our care of some of the most vulnerable. In this arena, we have a great deal of work to do to get there.