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 amongprisoners is substantially higher than it is in the community, with approximately ten percent ofprisoners suffering from a major mental illness, defined as schizophrenia, bipolar disorder, ormajor depression. Indeed, the Los Angeles County Jail has been called the largest de facto mentalhospital 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 inmany, if not most, prisons and jails are woefully inadequate. In the words of Stuart Grassian, aHarvard Medical School psychiatrist who has served as an expert witness in many prison mentalhealth cases, "I've seen people who are horribly ill, eating their own feces, eating parts of theirbody, howling day and night and it's ignored, like 'who cares?' You think it belongs to someother century, but you go into the prison and you think you're back in some medieval torturechamber. The prison has become this place that's hidden and secret and it's really awful." Giventhe lack of resources available to treat prisoners with mental illness, it is not surprising that thesuicide rate in prisons and jails is much higher than in the community as a whole. Nor is suicidethe only risk. Prisoners with untreated mental illness are also vulnerable to victimization by otherinmates, may pose a threat of assault to correctional officers and staff, and can seriously disruptthe prison routine. They are also likely to face discrimination in classification, access torehabilitative programs, and parole.

Constitutional Principles

    Since there is little public or political support for quality mental health care for offenderswith mental illness, prisoners have been almost entirely dependent on the courts for protection oftheir right to treatment. Dozens of class action law suits have successfully attacked the overallquality 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 claimof inmates to mental health services is Estelle v. Gamble, 429 U.S. 97 (1996), where the SupremeCourt held that the Eighth Amendment's prohibition against cruel and unusual punishment endowsall inmates with a right to medical care. Specifically, the court ruled that prison officials may notexhibit "deliberate indifference" to the "serious medical needs" of inmates. Thus, an EighthAmendment claim has two basic elements: an objective component, the existence of a "seriousmedical 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 constitutionalrequirements in this area, however, are often murky and inconsistent. For example, courts haveconsiderable difficulty in deciding what mental health needs are "serious" enough to mandatetreatment. Compare Steele v. Shah, 87 F.3d 1266, 1267 (11th Cir. 1996) (prisoner who "sufferedfrom insomnia, anxiety, and various bodily pains" and "feelings of helplessness" stated a claimunder 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 appetitesuffered merely from "mild, stress-related ailments" and "routine discomfort" did not have a"serious" medical need). Generally, however, prisoners have a right to psychological orpsychiatric 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 seriousdisease 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 besubstantial." Bowring v. Godwin, 551 F.2d 44 (4th Cir. 1977). Thus, mild depression and anxietyassociated with the stress of the prison experience will not be regarded as a "serious," while anycondition that is diagnosed by a doctor as mandating treatment must receive professional attention.    Discerning whether or not prison officials have demonstrated the requisite "deliberateindifference" can be similarly confusing. It is not enough that prison officials exercised poorjudgment, or that they were negligent or even grossly negligent; rather the inmate must show thatthe prison official was at least reckless, and reckless in the criminal sense, meaning that he or shehad 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 bydeliberately remaining ignorant about the need for treatment. They will still be held accountableif they deliberately disregard a known risk, even if they are ignorant of the details of a particularinmate's situation.

Basic Components of a Prison Mental Health System

    While there may be controversy about whether a specific inmate has receivedconstitutionally acceptable care, the courts have established a clear set of minimum requirementsfor an adequate system of prison mental health care. Further, a number of professionalorganizations, such as the National Commission on Correctional Health Care and the AmericanPsychiatric Association, have promulgated standards governing mental health services in prisonsand jails. See e.g., National Comm'n on Correctional Health Care, Standards for Health Servicesin Prisons (1997). Although courts are fond of saying that the professional standards may wellexceed the constitutional floor, they often utilize such standards, both to evaluate the quality ofmental 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 moredetailed account, including citations to professional standards and cases, consult the Summary ofProfessional Standards Governing Mental Health Services in Prisons and Jails published byATTAC in 1998.

1.    Screening and Evaluations

    The first requirement is that every inmate be screened upon admission in order to identifythose with mental illness or developmental disabilities. This generally entails a standardized setof 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 possiblysuffering from a mental disorder are promptly referred for a comprehensive mental healthevaluation and any necessary treatment. The threshold for referral for services must be low, bothupon admission and later, since it is easy for mentally ill inmates to escape notice in the prisonenvironment so long as they do not engage in egregiously bizarre behavior. In addition, inmatesmust be monitored throughout their incarceration in the event they develop signs and symptomsof mental illness. It is crucial that inmates who are in segregation or solitary confinement beassessed by mental health staff at least once per week. It is also vital that the institution have aprogram to identify and supervise suicidal inmates and those in crisis.

2.    Treatment Modalities        

    Correctional institutions must provide a range of meaningful treatment modalities toinmates identified as having a mental disorder. Although many prisons and jails simply confinementally ill inmates to segregation units where they can be closely supervised, this is notacceptable. The institution must make available psychotropic medication if needed. Psychotropicmedication must be prescribed only by a psychiatrist and in accordance with contemporary medicalstandards. Psychiatrists or physicians should monitor all inmates on psychotropic medications andre-evaluate the patient before renewing the prescription. Further, the prison formulary shouldcontain a range of psychotropic medications.

    Medication alone, however, is not sufficient. It must be part of an overall program oftherapy, including individual and group therapy where appropriate, as well as crisis interventionservices. Each inmate with a chronic mental disorder should also have an individualized treatmentplan. In addition, the facility must provide qualified interpreters to ensure that non-Englishspeaking inmates have access to mental health services. Further, no inmate with a history ofmental 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 trainedstaff to provide treatment consistent with contemporary standards of care. This means the facility must have an adequate number of psychiatrists, psychologists, and other mental healthprofessionals, either on site or on call, to provide all necessary services. Although there are noclear standards quantifying an appropriate number of mental health professionals, expertsgenerally insist that the caseload of a prison psychiatrist should be no more than 125-150, and jailpsychiatrists should not have a caseload that exceeds 75-100. One of the worst consequences ofinadequate 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 theirillness may be equally severe, those who suffer quietly go unnoticed and unserved. This problemis exacerbated by the common failure to provide sufficient training to correctional officersconcerning 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 sometimesneed special housing separate from the general prison population to receive more intensivetreatment and supervision. This may range from a day treatment program within the prison, toa crisis unit for acutely psychotic or suicidal inmates who does not require inpatienthospitalization, to an intermediate level residential treatment unit for those whose level offunctioning makes them vulnerable to abuse from other inmates, are too disruptive for placementin the general population, or who need substantial therapeutic services. Since sometimes nothingshort of intensive inpatient hospitalization is adequate for an inmate who has decompensated, theinstitution must also have a procedure to transfer acutely mentally ill prisoners to a hospitalsetting.

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. Theinmate's mental health records must be kept confidential by maintaining them

separately from other records. When an inmate is transferred to another institution, his recordsmust 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 vitalthat the facility make an effort to ensure continuity of care after release. This may meanproviding the inmate with a medication prescription, as well as arranging for follow-up servicesin community mental health centers.

7.    Quality Assurance Program

    The institution must have a quality assurance plan to assure that inmates receive competentcare. This should include studies of utilization patterns and clinical outcomes in the facility as awhole, as well as analysis of the clinical record of individual prisoners.

    Although many prisons and jails have carefully drafted policies and procedures designedto meet their constitutional obligations regarding mental health care, there is often a wide gulfbetween what exists on paper and the services that are actually available. The quality of theservices and the physical plant is also often substandard. Thus, there is no substitute for thoroughfactual investigation in order to make an assessment of the adequacy of the mental health servicesin any jail or prison.