Academic journal article Stanford Law & Policy Review

A Reflection on the Madness in Prisons

Academic journal article Stanford Law & Policy Review

A Reflection on the Madness in Prisons

Article excerpt

INTRODUCTION  I. Oddities II. The Mentally Ill in Incarceration III. The Mental Effects of Double Incarceration or Isolation IV. Legal Interventions V. Beyond Legal Interventions 


On August 13, 2014, in one in a series of articles about the state of conditions at Rikers Island, New York City's main jail complex, the New York Times revealed:

   The portrait that emerged from the report on Rikers Island by the    United States attorney's office in Manhattan last week was of a    place with almost medieval levels of violence, meted out with    startling ferocity by guards and their superiors.      The two-and-a-half-year investigation, which focused on the abuse    of teenage inmates by correction staff, was exhaustive in    cataloging the brutality.      But a critical question that went unaddressed is how conditions    were allowed to get to this point.      Rikers has been a place of violent excess for decades. And the    growing ranks of inmates with mental illnesses, reaching nearly 40    percent of the jail population today, have added to the challenges    for correction officials. (1) 

The U.S. Attorney's Office report (2) and the Times investigative series were only the most recent salvos in a series of breaking news stories that have placed the experience of being a mentally ill inmate into the public discourse. Others have included legal rulings, such as the approval by Judge Lawrence Karlton of California's Eastern District of a plan to reduce mentally ill inmates in isolation in California prisons. Burgeoning commentaries in popular culture and conversation comprise only the surface of a growing civic movement. (3) For many readers of those reports, the contents were shocking and new; however, there is a significant medical and legal literature that has long documented these facts. From the mental health practitioner's perspective, this Article will explain that literature; how imprisonment affects those with and without mental illness, especially through solitary confinement (a condition that befalls those who are mentally ill especially frequently); and what to do about it.


Prisons are odd places for the psychiatrist to be practicing mental healthcare, yet they are our de facto mental institution. The above reports reiterated what the senior author4 of this Article saw in her daily work as a staff psychiatrist at Rikers Island. There, she treated hundreds of inmates with mental illness next door to the facility's emergency medical clinic, which received a daily flow of inmates beaten to the point of losing consciousness. Treating the damage seemed paradoxical in a setting where injuries were so often the deliberate product of other inmates or, as documented in the Rikers report above, the guards themselves. Less visible but equally present were the psychological injuries. Thirty minutes of therapeutic intervention per month would be counteracted by 731.5 hours of punitive, degrading, and wounding treatment. Medication often did not get delivered by staff, who might find it inconvenient to wake a patient at four-thirty in the morning, even if the patient, desperate to receive it, had been awake much of the night trying not to miss it (inmates are usually not allowed to hold psychiatric medications themselves).

And what happens to the severely ill? Since a loss of insight, and the accompanying refusal to admit that one is ill and needs help, are hallmarks of many mental illnesses, those who need care the most are the least likely to receive it. In fact, many severely ill individuals did not even get to the psychiatrist's office for an evaluation. Once, when asked to screen an inmate being taken into punitive segregation for not following orders, the senior author found him to be floridly psychotic--yet he was miscategorized as someone without any mental health problems because he was withdrawn, quiet, and in denial of his illness. …

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