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Mental health care in the United States today is at a crisis point. Nowhere is this crisis more evident than looking into the criminal justice system. Beginning in the 1970's, the Community Mental Health Act deinstitutionalized "all inmates of the asylum that were not a 'clear and present danger' to themselves and society" (Allen et. al, 2013, p. 390). Since then, the closing of 90% of state and community mental health facilities has had an tremendous effect on another institution: the correctional facilities. The decline in the use of state mental institutions has resulted in the mentally ill being cast into the streets, often resulting in incarceration for minor offenses such as trespassing, theft, indecent behavior or public intoxication. Their mental illness combined with drug abuse which is quite common with street life, can however result in dangerous and destructive behavior. Since most states today do not have the capacity to accommodate the mentally ill in a treatment facility, they are sent to prison instead.
In prison, they are treated with medication, examined by physicians, psychologists and counselors and recover from their illness to an extent that they are able to be released to live a "normal" life. The reality is, however, the recidivism rate for the mentally ill is astounding. Within 18-months of their release, nearly two-thirds will find themselves back behind bars. With little to no support system awaiting them in the free world, they often struggle to maintain a supply of their medication, remember to take any medication they have, find housing or a job. They often become homeless and stop taking their medication. . Their inability to assimilate to freedom once again finds them decompensated, off their medication and back into the system to start the cycle over again; being arrested either for minor or violent crimes and their return to incarcerated life - the only life that is able to provide them with a routine of proper care. This creates a revolving door of treatment and rehabilitation followed by decompensation and incarceration for many of the mentally ill.
The state of Colorado is no exception to this scenario. In 2009, the National Alliance on Mental Illness (NAMI) gave Colorado an overall grade of C in their care provided to the mentally ill. The state received an F in Health Promotion & Measurement, a B in Financing & Core Treatment/Recovery Services, a C in Consumer & Family Empowerment and a D in Community Integration & Social Inclusion. Not surprisingly, the areas in need of the most improvement included workforce development, housing, jail diversion programs, availability of reentry programs, mental illness public education efforts and per capita mental health courts. The state received a grade of zero in many of these categories and fell well below the average U.S. score in others. On the other hand, the Colorado Department of Corrections (DOC) Mental Health Unit:
provides and manages cost effective mental health services to offenders. Services are provided to diminish the risk to public and institutional safety, and maintain or improve offender level of functioning. The DOC provides a wide range of professional psychiatric, psychological, social work, and mental health treatment services to offenders incarcerated in the DOC. The DOC Mental Health Unit manages the mental health needs of the offender population from intake at the Denver Reception and Diagnostic Center (DRDC), throughout their incarceration, and provides specialized transition services for targeted populations as they leave the facilities to parole, community corrections placements, or discharge. (DOC, 2012)
The funds and care appropriated to the criminal justice system as opposed to the Division of Mental Health in Colorado for the care of mental illness is a clear indication of the volume of inmates with mental illness that the correctional facilities receive. The criminalization of persons suffering from mental illness is a "critical component of the escalating prison populationâ€¦ who at one time would have been treated in mental hospitals, are displaced into correctional facilities" (O'Keefe & Schnell, 2007 p.82). Data gathered by O'Keefe and Schnell (2007) indicates that nearly 25% of U.S. inmates incarcerated in state facilities are mentally ill while the approximation of mental illness in the general populous accounts for only 2.6% making it obvious that they are disproportionately represented in the criminal justice system.
In the Unites States today, with mental health care in its current state, it is practically impossible to separate mental health care from the correctional system. An offender's first experience within the correctional sytem, whether mentally ill or not, is usually with an arrest being made and sent to a locally operated jail. Thus, it is essential to provide training and appropriate training to those who serve the communities at the most provincial level to understand mental illness in an offender so that they may be directed to the proper institution for care. Public awareness and increased government recognition in recent years has seen the development of jail diversion programs to increase screening and treatment options at the local level. Additionally, mental health screening and treatment is now required to be "provided as a matter of policy so that psychotropic medications are prescribed and counseling is done by trained mental health providers in all Federal prisons and most State prisons and jail jurisdictions" (Davis, Fallon, Vogel, & Teachout, 2008, p.218). This seems to be a step in the right direction, however, while the program requires the availability of the service, access and quality of service or rather the lack of, has rendered such programs to be "ineffectiveâ€¦and incompatible with therapeutic efforts" (David et al., 2008, p. 218). One of the most important and difficult challenges faced by the correctional systems is identification of mental illness. Screening for mental health at the time of intake becomes a vital part of the process to determine whether an offender requires psychological treatment or to be places in a mental hospital, at least temporarily, rather than to be incarcerated. Offenders with a mental illness require treatments, medications, and social support needs that significantly differ from other, non-mentally ill offenders in order to assist them with the ability to cope with prison life. O'Keefe and Schnell's research provided that the strongest contributing factor to the identification of mental disorders is a charted history of mental illness. Offenders with a recorded treatment history saw a 91.7% detection rate of mental illness whereas only 32.5% were detected when treatment histories were unknown (2007, p. 84). The conventional challenges confronted by any incarcerated person with a mental health problem are inflated dramatically when focused on these offenders' ability to function in a correctional setting. As stated, research has shown that, many of the mental health needs of offenders often go undetected and/or untreated in correctional settings. This has "serious implications for the inmate, the individuals surrounding them in the institution (other inmates and staff alike), and the community at large, when the inmate is eventually returned to society" (Olley, Nicholls & Brink, 2009).
Community based care is vital to the success and rehabilitation of mentally ill inmates that have been released. Many of these former inmates have very little family, friends or community which will provide a support system during their transition from incarceration back into society. Those who are released into the custody of parole or probation often find success for the duration of their stay at a half-way house or while probation officers are available to monitor their progress and ensure they are taking their medications. Those who have completed their sentence and are simply released, or "maxed out" of the system, fare worse as they usually have no home, job, stability or support awaiting them to ease the transition. Without support incorporated with mental health care, "substance abuse, employment, and other services, many people with mental illness end up being homeless, disconnected from community supports, and thus more likely to . . . become involved with the criminal justice system" (Davis et al, 2008, p. 219). According to John Suthers, the executive director of the Colorado Department of Corrections, only 5% of the prison population was chronically mentally ill. By 1999, the number had doubled and "95% of them would be returning to our communities, where they'll have very little support. They'll probably stop taking their medication, and many of them become violent without it. That'll force them back into the criminal justice system" (Groom, 1999, p.115).
Over the course of a decade beginning in 1995, the Pennsylvania Department of Corrections has enhanced the "continuity-of-care policies and procedures for inmates with mental illness and co-occurring disorders, and developed programsâ€¦ to assist inmates with reentry into the community" (Couturier, 2005, p. 83). The Community Orientation and Reintegration program developed by the Pennsylvania DOC and described in Couturier's article (2005) is a two-phase program designed to enable inmates' transition from the prison environment to their home community. The program provides an individualized agenda based on the inmate's ability levels and progress level attained within the correctional facility. The first phase of the program as described by Couturier (2005) is completed in the prison during the several weeks prior to discharge and addresses the critical issues of parole responsibilities such as "employment preparation, vocational evaluation, personal finances, substance abuse education, Alcoholics Anonymous/Narcotics Anonymous meetings, housing, family and parenting, mental health, life skills, antisocial attitudes and community (give back) services" (Couturier, 2005, p. 83). The second phase of the program prepares inmates to return to the community over a four- to six-week program individually designed to the best capabilities and interests of the offender. The Pennsylvania Board of Probation and Parole and DOC community corrections staff establish a release date for the inmate as to when he is able to leave from the community corrections center based upon his progress. If necessary, program procedures can be modified to meet the needs of an offender with special needs. This kind of program greatly benefits not only the inmate as his transition to the community is monitored and supported; it is also beneficial to the community receiving the former inmate as their chances of assimilating to the community increase their potential threat to the community decreases.
The Colorado Department of Corrections opened the San Carlos Correctional Facility in 1995 in response to the increasing number of mentally ill inmates that required special needs. The facility supports a capacity of 255 beds and is ran more as a "therapeutic community" much like a rehabilitation center for addicts rather than a traditional "lock-down" prison and is able to provide "specialized treatment, care, and programming to mental health special need male offenders in a Level V Correctional Facility. Prepare offenders for successful community re-entry or successful reintegration into Colorado Department of Corrections' Facilities. Promote a positive work culture with innovative management practices in an ethical, professional, and responsible manner by empowering employees and promoting staff development" (SCCF, 2012). Programs provided to prisoners at the San Carlos facility in order to aid in transitioning to society include: Adult Basic Education, Work Activity Center where offenders learn basic skills such as sewing, using a time clock and responsible behavior in a work place, Mental Health classes in: Understanding Your Mental Illness, Symptom/Medication Management, Institutional Coping Skills and Addiction Recovery Programs according to their website (SCCF, 2012). Once released, they are sent to a halfway house where the "residents continue an after-care program where they learn to live and work in the community" (Groom, 1999, p. 119) as well as receive psychiatric care and access to their medications.
Although protection of autonomy for those with a mental illness is essential, the rights of the inmates need to be balanced with the necessity of providing care to those whom are not able to understand how the administration of mental healthcare is beneficial to them, the inmate population and to the correctional staff. Some authorities have
asserted the benefits of providing mental health services to incompetent prisoners; however, advocating involuntary treatment of individuals who decline to consent should be taken with caution, particularly in such a vulnerable population as inmates. It is advantageous for any civilized society to ensure adequate legal protection of the civil liberties of its marginalized citizens and that any such treatment is provided in compliance with applicable statute. The ethics and human rights requirements require careful monitoring and such treatment must clearly be in the best interests of the inmate (Olley, Nicholls & Brink, 2009, p. 829-830).
Although there are numerous challenges to providing appropriate mental health services to inmates experiencing mental health problems, the moment of opportunity that is available when an individual with mental health needs is in correctional custody should not be ignored. Many individuals receive their first real, complete mental health evaluation upon entering the correctional system. Their and the attentive care that they receive can offer a therapeutic window which otherwise may not have been available to the offender at any other time in their life. Clinical and research experiences in jails and prisons have found that "inmates frequently report that their admissions to corrections is the first time they have been asked about their psychiatric symptoms, their suicidal thoughts or behaviors, and their mental health needs, or had an opportunity to experience the relief brought about by antipsychotic or mood stabilizing medications" (Olley, Nicholls & Brink, 2009, p. 830).
Prison is not an easy place to acclimate to. The function of a prison is to first and foremost provide safety and security to the community it serves; not to provide mental health treatment. Prison life comes with a set of strict rules, regulations, orders and standards that must be maintained by every prisoner regardless of their mental capacity to do so. Despite the provisions of medication, therapy, and other mental health services provided by the correctional system; it is nevertheless true for those with suffering from a mental illness that prison life can aggravate aspects of the illness resulting in behavioral disruptions. Medications relieve many of the manifestations of mental illness that perpetuate behavioral infractions; therefore, disruptive behaviors are most likely to occur when the inmate is not taking their medication. Many mentally ill inmates refuse to take medications, and when this occurs, prison staff typically cannot forcibly administer them without a court order. Noncompliance occurs because the inmates want to avoid unpleasant side effects or benefit from selling or bargaining medications for desired amenities (O'Keefe & Schnell, 2007). Detrimental effects of medication noncompliance are further agitated by environmental variables. The prison environment is comprised of many adverse conditions that negatively affect all prisoners, such as overcrowding, excessive noise and uncomfortable temperatures. Lack of autonomy, physical confinement, and humiliation can evoke fear and stress. The abrasive atmosphere in correctional facilities, when compounded by mental illness, can easily trigger behavioral infractions such as yelling and aggressive behavior toward other inmates and staff, which lead to punitive consequences. O'Keefe and Schnell (2007) also site a study conducted in 2006 that further provided evidence of prison adjustment issues where 58% of offenders with a mental illness were charged with rule violations in comparison to only 43% of non-mentally ill offenders. Additionally, the offenders' behavioral disturbances can sometimes agitate other inmates and result in aggression towards the individual causing the annoyance. Correspondingly, it was found that mentally ill offenders were twice as likely to sustain a fighting injury as their non-mentally ill counterparts (O'Keefe & Schnell, 2007 p.87). Noncompliance with the regulations of the facility result in disciplinary action which can extend the sentence of an inmate sometimes far beyond the recommended sentencing guidelines for the crime they committed. Carl McEachron, an inmate at the maximum security prison in Lucasville, Ohio featured in PBS' Frontline's documentary The New Asylum, has been in prison for 16years on a three year sentence for burglary on account of the countless disciplinary actions (Navaski & O'Connor, 2005).