Why America’s Largest Mental Health Institutions are Prisons and Jails

In the U.S., prisons and jails are the largest institutions housing adults with serious mental health and/or substance use disorders. Individuals with severe mental health disorders occupy at least 1 in 5 of America’s prison and jail beds.

America is caught in a vicious cycle. We have returned to colonial era modalities, using jails and prisons to warehouse individuals with mental illness. A report published in 2014 by the Treatment Advocacy Center, a Virginia based non-profit group that promotes access to mental health care, chronicles America’s history of the problem. In summary, as early as the 1700’s, “voices of protest in the colonies, claiming that confining mentally ill persons to prisons and jails was inhumane,” led to the nation’s first psychiatric ward at the Pennsylvania Hospital in Philadelphia in 1752 and the nation’s first psychiatric hospital in Williamsburg, VA in 1773. In the 1800’s movements exposing pervasive and appalling treatment and conditions in the nation’s state prisons and county jails led to a widespread acceptance that individuals with mental illness belonged in hospitals. By 1880, 75 public psychiatric hospitals existed in our young nation. An 1880 census concluded that less than 1% of individuals contained in prisons and jails were “insane.”

In the 1960’s and 70’s, deinstitutionalization, the government’s movement to reduce the nation’s state psychiatric hospital population, prompted a return to an era of prison “asylums.”  This policy cited as its impetus that it was inhumane to keep individuals locked up in hospitals, often times under unacceptable, even abusive conditions, and that people would be better served and experience a better quality of life living in the community, receiving services through special programs. While the concept was well-intended and indeed research has proven that many individuals with behavioral health disorders fair better, and even thrive while receiving treatment in community settings and with the support of family and friends, this policy lacked an important ingredient–knowledge about how programs and services could evolve and be funded in order to meet and keep up with the need.

So what has replaced hospitals? The graph below shows how America has cycled from colonial era incarceration of individuals with mental illness back into a similar modern-day scenario. (TAC 2010: More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States)

Retired executive director of the community Behavioral Health Association (CBH) of Maryland, Herb Cromwell, says in a  Mental Health Weekly Article from September 2015,
“We’ve seen the evolution of a thriving family support movement [in Maryland] and nationally, and a vibrant consumer movement. Stakeholders are very much at the policy making table, as they should be…For the last 25 years, I’ve worked directly with mission-driven community providers who’ve made services more comprehensive, accessible and effective.” He admits however, “Obviously there’s much more work to be done,” noting that too many people with mental illness and addictions are in jails and prisons.
According to the Treatment Advocacy Center’s 2014 report, “In 2012, there were estimated to be 356,268 inmates with severe mental illness in prisons and jails.” That translates to 20% of inmates in jails and 15% of inmates in state prisons.
Mr. Cromwell also explains that,
“Public-sector budget support lags far behind the need. Private insurance reimbursement for mental health treatment, despite new parity laws, is still so poor that it discourages provider participation in plans and reduces consumer access to care.”

Compounding the problem today is the fact that many inmates with mental health disorders also have a co-occurring substance use disorder. A 2010 report, published by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, also found that “of the 2.3 million inmates crowding our nation’s prisons and jails, 1.5 million meet the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) medical criteria for substance abuse or addiction. Another 458,000 inmates, while not meeting the strict DSM-IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation; or share some combination of these characteristics.”

Some of the major problems associated with the incarceration of individuals with behavioral health disorders include:

  • Worsening of psychiatric symptoms: often behavioral health disorders go undiagnosed and/or untreated in correctional systems
  • Substance use disorders are not addressed: inmates don’t often receive treatment for substance use disorders and are more likely to use again once released
  • Abuse by corrections staff: many of the correctional officers do not understand, and have little or no training in how to work with inmates who have mental health disorders and resort to disciplinary measures such as pepper spray, physical force or solitary confinement which can exacerbate symptoms, and do little to correct behavior
  • High rates of recidivism: inmates leaving jails and prisons often receive little, if any, psychiatric aftercare leading to continued criminal behaviors and re-incarceration
  • Jail and prison overcrowding: not only have jail and prison overcrowding  become human rights and constitutional issues, but they have an impact on the levels of inmate violence and can stretch resources such as staff too thin

Behavioral health treatment programs dedicated to improving the lives of individuals with substance use disorders and co-occurring mental health and substance use disorders, have been proven to help reduce incarceration and recidivism among offenders with and without mental illness.

In Anne Arundel County, the Department of Detention Facilities has taken steps to address the increasing number of persons with mental health and substance use disorders entering ORDD (Ordnance Road Correctional Center) and JRDC (Jennifer Road Detention Center) by partnering with the county’s Mental Health Agency to provide behavioral health services to inmates. Many individuals receiving treatment in Arundel Lodge’s First Step Recovery Program are also from the jail and prison system, or are court ordered for substance use treatment.

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