Should inmates be allowed to continue their mental health treatment?

By Sarah Sidlow | Illustration Michael de Adder

Q: After mentally ill inmates are released from jail or prison, should they still have access to their treatment?

Fact: American prisons were never designed to be mental health providers.

Fact: According to the Bureau of Justice Statistics, 56 percent of state prisoners and 45 percent of federal prisoners have symptoms or a recent history of mental health problems.

Mental illness in American jails, prisons, and federal facilities is pervasive. Studies in this arena often point to the cooperative effects of mental illness and violence, drug abuse, and dangerous behavior. Statistically, as the population of inmates increases, so does the population of inmates with mental illness.

Many prisoners—the Journal of the American Academy of Psychiatry and the Law estimates as many as one in three—receive some sort of mental health treatment while imprisoned. But what happens when they walk out those doors and into the sunshine? Should their treatment follow them onto the pavement?

For many, the answer is unequivocally “yes.” Without continued treatment, they argue, it is nearly hopeless to expect a former inmate with mental illness to adjust to civilian life and become a functioning member of society.

To many, the spirit of the incarceration system is reform—taking people who need to be removed from society, and guiding them until they can successfully play by the rules. If this is the mission, they argue, then it follows that mental health treatment should be available to newly freed prisoners. By helping prisoners regain health and improve coping skills, you not only ensure a more successful transition into the community, but you also promote community safety.

Others argue that access to mental health care is a fundamental human right—devoid of judgment for character, color, or country of origin. Whether a murderer or a middle school teacher, mental health treatment should be extended.

Yet, for others, additional mental health services just add up to more taxpayer burden. That isn’t to say that mentally ill prisoners don’t deserve help—it just shouldn’t come out of the community coffers. A 2014 report by the Brookings Institution’s Hamilton Project found that each U.S. resident on average in 2010 contributed $260 to corrections expenditures. Check please!

Other research argues that mental health care doesn’t top the list for most offenders getting out of jail—in fact, among the basics like food and shelter, mental health care rarely tops the priority list for new releases.

That said, if a former inmate does feel the need to continue treatment, many argue they should have to get it the same way any other mentally ill person would: get a job, get health insurance, and find treatment.

Q: After mentally ill inmates are released from jail or prison, should they still have access to their treatment?


Yay: The affordable chair act

Mental health treatment for prisoners is a right, not a privilege

By Ben Tomkins

The problem of mental health treatment for prisoners as they leave correctional institutions is a classic collision of solipsism and solidarity in a free society. From a legal perspective, locking a person in a box is the difference between healthcare being a privilege and a right in the United States. Ruiz v. Estelle established that prisoners have a right to “adequate”—a squirrelly term if ever there was one—mental and physical healthcare while they are in prison.

The foundation of the principle is very simple: if you tie a man’s hands, you can’t leave him for dead. You are bound to him insofar as you have bound him, and in prisons, that means we must provide healthcare. We incarcerate more people here than any other First World country, and the result is, as Anasseril Daniel states in the Journal of the American Academy of Psychiatry and the Law in 2007, our prisons have become our “de facto state hospitals,” as “there are more seriously and persistently mentally ill in prisons than in all state hospitals in the United States.”

The need for post-incarceration coverage was addressed by the expansion of Medicaid under the Affordable Care Act, but the mere creation of a framework to cover former inmates didn’t mean they were actually folded into coverage. Not all states have adopted the expansion, and in many that have, bureaucracy and tepid enrollment efforts have hindered its effectiveness.

In the end, the fact remains that once a prisoner becomes an ordinary citizen again, we no longer consider the treatment of their mental health something to which they have a fundamental right. If they choose to go off their medication or cannot continue for a myriad of reasons, then we are more willing to deal with the consequences than we are to fund preventative care. For better or for worse, the American conscience seems relatively clear on the point that disengaging our humanity and compassion towards one another is justified in free society, and current political trends have their sights fixed on creating a more structured in-group/out-group mentality.

Who are the “good Americans” deserving of help with their problems? Those whose problems don’t require more money than they could earn in the workplace with a decent job. Given a choice, we’ll invest in creating one job for five people to fight over before funding a soup kitchen, and then use an electric chair as shock therapy when the four losers crack.

The flat truth of the matter is that human beings are highly imperfect physiological and psychological beings. We live in societies because we are social beings, and the irritations, dangers, and natural conflicts that arise are predictable and inevitable consequences of our infinitely varying menu of limitations and flaws colliding with reality.

We anger too quickly for the sardine can that is city living, and the chemicals that flood out of our various glands as a result poison the clear waters of reason with an oil slick of irrationality. The appendages of medical science have advanced the understanding of what it means to be mentally healthy to a stage where the World Health Organization defines “health” as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” For all practical purposes, they may as well have said, “having attained transcendental enlightenment, and being profoundly satisfied with the consistency of one’s poop.”

Even the most docile of us could use an extra stalk of celery and a day off. We are all failure-riddled creatures in a highly stressful world, and as that pressure ratchets up through poverty, disease, drugs, and violence, we are all more likely to snap. Prison is a powder keg for the psyche, and ideally, when an inmate returns to outside society, we would like them to be able to find a little corner of it in which to settle down and live a decent life without causing any undue commotion.

How anyone thinks that this end will be achieved by ripping the scab off of someone’s mental health issues just as they make a major life transition is beyond me. It is so obviously inviting failure for an individual and disaster for society at large that, but for our woefully inadequate capacity for critical thinking, it’s virtually inconceivable that we allow those circumstances to exist. And the most obvious answer is not one that singles out former inmate mental health as needing special government agencies and programs, but one that grants access to mental healthcare to everyone. The advent of civilization was a choice we made to replace physical strain with psychological strain, and mental illness is the systemic disease of the citizen. The need for continued care for former inmates is merely an obvious example of the symptoms.


Yay: Weighing the cost

No mental health treatment after prison means a greater security risk for us all

By David H. Landon

Almost 400,000 inmates in the U.S. prison system are estimated to be mentally ill. The problems range from severe mental health conditions, like schizophrenia or bipolar disorder, to the more common issue of depression. For many, their untreated illness may have played a primary role in landing them in prison. Many of these inmates receive some sort of mental health treatment while imprisoned, and for some it might be the first time they have received any care. This care is thought by many to be worth the expense, as it may help modify the behavior that landed the inmate in jail in the first place. One goal of incarceration is rehabilitation—without addressing the underlying reasons for the anti-social behavior of these troubled individuals, there is little chance of rehabilitation.

But should society continue to pay for mental health care after the individual is released from custody? Like so many decisions affecting public policy, the cost/benefit ratio should be taken into consideration in deciding whether or not taxpayers should continue to hang on the hook for someone who has broken the law, perhaps related to or exasperated by their illness, spent time in jail, and then, still suffering from mental illness, is released into society. This is not a question of first impressions. Numerous studies have shown that continued treatment reduces the rate of recidivism on the part of these individuals. In short, it is cheaper to continue their treatment than to roll the dice in hopes that the individual can reform their behavior without professional help. Medicare covers many of the individuals suffering from mental illness, however, that coverage is terminated when a person enters a county jail. This creates a gap in coverage when inmates are discharged, causing those with mental illnesses to go weeks or months without medication.

There are legislative programs which mandate involuntary outpatient treatment, and this legislation has helped to increase access to care for those at risk—one example is Kendra’s Law. This law was enacted in 1999 following the death of Kendra Webdale. Kendra was pushed in front of a New York City subway by a man with untreated schizophrenia. The law provides for outpatient mental health treatment for individuals who are unlikely to survive safely in the community without treatment. A recent study conducted by Duke University researchers found that Kendra’s Law resulted in a net 50 percent reduction in overall costs in New York City for treatment of those who went into the program.

The financial balancing test would seem to suggest that the cost of continued treatment is less than the cost of housing these individuals back in our jails and prisons. And there is a greater risk to the public for releasing a mentally ill person back into society without any follow up treatment—just think about the increasing concern surrounding mental illness and gun violence.

The nexus between mental health and gun violence has become more and more obvious as the nation watches in horror as these mass shootings continue to plague our society. Reports suggest that up to 60 percent of mass shootings in the United States since 1970 were undertaken by individuals who displayed symptoms of mental illness. These individuals displayed symptoms of depression, delusions, and acute paranoia before committing their crimes. In Aurora, Colorado, the movie theatre shooter “was seeing a psychiatrist specializing in schizophrenia” before he opened fire in that crowded theatre. It was reported that the classmates of the gunman who shot U.S. Congresswoman Gabrielle Giffords and six other people, felt unsafe around him because of his erratic behavior in the weeks before the attack. These are just two examples out of many.

The focus on mental illness in the wake of recent mass shootings reflects a decades-long debate about guns, gun violence, and “mental competence.” Would stricter gun control have stopped some of these recent tragedies? Or would a prohibition on any individual showing any signs of serious mental illness have been more effective in stopping the senseless mayhem caused by these shootings?  After the 2012 shooting at Newtown, a noted psychiatrist, Dr. E. Fuller Torrey, issued warnings about dangerous “subgroups” of persons with mental illness who, he contended, were perpetrators of gun crimes. Speaking to a national television audience, Torrey claimed that “about half of . . . mass killings are being done by people with severe mental illness, mostly schizophrenia, and if they were being treated they would have been preventable.”

So how do we keep guns out of the hands of those who are mentally disturbed?  Does such prohibition violate any second Amendment rights of those individuals? The answer would seem pretty obvious—it is sound policy to separate these individuals from guns, and doing so withstands Second Amendment scrutiny. If such laws are in existence that would help keep guns out of the hands of the mentally ill, enforce them. If such laws are vague, pass new and forceful legislation which clearly takes the guns out of the hands of those individuals. The U.S. Supreme Court, which strongly affirmed a broad right to bear arms in 2008, endorsed prohibitions on gun ownership “by felons and the mentally ill” because of their special potential for violence. This seems like a policy with which we could all agree.

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Reach DCP editor Sarah Sidlow at SarahSidlow@DaytonCityPaper.com.

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