Tuesday, April 8, 2014


In few places are the consequences of non-treatment more visible than in jails and prisons, said the Treatment Advocacy Center

(ARLINGTON, VA.) The first national study to examine the policies and practices under which mentally ill inmates receive treatment was released today by the Treatment Advocacy Center and the National Sheriffs’ Association.

The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey
” reports that 10 times more individuals with serious mental illness are in state prisons and county jails than in the nation’s remaining state mental hospitals – an estimated 356,000 mentally ill inmates compared with 35,000 patients.

Background in Kentucky  
The Eastern Kentucky State Prison in West Liberty (1,705 inmates) and the Louisville Jail (1,353 inmates) both hold approximately the same number of individuals with serious mental illness as do the two state hospitals, Western State (205 patients) and the newly rebuilt Eastern State (239 patients). The county jails are plagued by revolving-door inmates who are mentally ill. According to an official at the Louisville Jail, “their average stay is about 18 days and in the past five years they have been in jail 140 times” (Courier-Journal, Nov. 24, 2012).
Kentucky’s prisons have also had increasing problems associated with the rising number of mentally ill prisoners.

Photo by Jenn Ackerman
Such problems were graphically demonstrated in 2013 by a series of photographs, entitled “Trapped,” taken in the Kentucky State Reformatory by photographer Jenn Ackerman. They include pictures of an inmate in a spit mask, to prevent him from spitting at the doctors or correctional officers, and they visually illustrate how difficult such living situations are both for the mentally ill inmates and for those who have to take care of them. As Ackerman summarized it: “The reason for my project wasn’t to show how terrible the conditions were in the prison; it was to [ask], ‘Is it really where we want these men to get treatment?’ We need to focus our energy on finding funding for mental health before this ever happens. The only place many of these men have been able to get treatment has been in prison” (Slate, Apr. 1, 2013).
Current Laws Governing Treatment in Prisons and Jails
Kentucky Department of Corrections (KY DOC) policies and procedures allow for nonemergency involuntary medication if an inmate suffers from a mental disorder and poses a likelihood of serious harm to self, others, or property, or if the inmate is gravely disabled.
Likelihood of serious harm means:
a risk that a patient may inflict physical harm upon himself as evidenced by verbal or written threats, gestures, past behaviors or attempts to inflict physical harm on one’s self, upon another, or upon the property of others.
Gravely disabled means a condition resulting from a mental disorder:
(1) which causes a person to be in danger of serious physical harm resulting from a failure to provide for his own essential human needs for health or safety; or
(2) in which the person manifests severe deterioration in routine functioning as evidenced by repeated and escalating loss of cognitive and volitional control over his actions and is not receiving care essential for personal health and safety.
Authorization of nonemergency involuntary medication is determined through a Washington v. Harperadministrative proceeding by an Involuntary Medication Hearing Committee composed of a nontreating psychiatrist and a nontreating psychologist as well as a high-ranking staff member who serves as chair of the committee. A majority of committee members must approve nonemergency involuntary treatment; the psychiatrist must be in the majority. 
Photo by Jenn Ackerman
State law does not prohibit Kentucky county jails from administering medication involuntarily on a nonemergency basis. Therefore, county jails could use a Washington v. Harper administrative proceeding to authorize involuntary medication for an inmate who is suffering from a mental disorder, is gravely disabled, or poses a likelihood of serious harm to himself or others. Based on the survey information, at least one jail has used a Washington v. Harper procedure in the past. Typically, Kentucky jails petition for civil commitment to state or community psychiatric facilities.
Note: Kentucky’s high rate of suicides in jails prompted the Kentucky legislature to invest in a new statewide program for integrating mental health services provided to jails. One component is a Telephonic Triage service to assist jails in assessing the safety of an inmate with mental illness. Based on telephonic assessments, recommendations are made for additional follow-up services that may include a face-to-face visit by local mental health professionals to evaluate inmates for civil commitment to a psychiatric facility.
The consequences of failing to treat individuals with serious mental illness in prisons and jails are usually harmful and sometimes tragic, the survey found. Without medication, the symptoms of the inmates’ mental illness become worse, leading them to sometimes behave in disruptive and bizarre ways. Such mentally ill inmates are vulnerable to being beaten, raped or otherwise victimized; are frequently put in solitary confinement for long periods; and sometimes mutilate themselves or commit suicide. Mentally ill inmates also contribute to the overcrowding of prisons and jails and to the increasing cost of corrections for both states and counties.

Kentucky uses a committee procedure allowed under a 1990 U.S. Supreme Court decision for providing involuntary treatment for prison inmates with serious mental illness whose symptoms render them dangerous or likely to deteriorate into dangerousness. This procedure is now sanctioned by law for state prisons in the majority of states and for a few county jails but it is only rarely used. Barriers to similar treatment for county jail inmates who are symptomatic result in the use of restraints, seclusion or observation rather than medication, the report said.

In almost every state, a prison or jail is now de facto the largest mental institution in that state. In Kentucky, the Louisville Jail and the Eastern Kentucky State Prison apparently each hold about the same number of individuals with serious mental illness as the two state mental hospitals, according to the study.

“The lack of treatment for seriously ill inmates is inhumane and should not be allowed in a civilized society,” said Dr. E. Fuller Torrey, founder of the Treatment Advocacy Center and lead author of the study. “This is especially true for individuals who – because of their mental illness – are not aware they are sick and therefore refuse medication.”


•    Maintain a functional public mental health treatment system so people with mental illness do not end up in prisons and jails

•    Reform mental illness treatment laws and practices to eliminate barriers to timely treatment before people commit crimes

•    Reform jail and prison treatment laws so prisoners with mental illness receive appropriate and necessary treatment,  just as inmates with other medical illnesses already do

•    Use court-ordered outpatient treatment – identified by the Department of Justice as an evidence-based practice for reducing crime and violence – to help at-risk individuals live more safely and successfully in the community

•    Implement and promote jail diversion programs

•    Institute mandatory release planning. A recent study reported that inmates who are not treated following
release have an almost four times higher rate of committing additional violent crimes compared to those who receive treatment.

“The mistreatment of inmates in jails in prisons, including the denial of proper medical care, is a national embarrassment and has led to international condemnation,” Torrey said.  “Mentally ill individuals who end up in prison or jail should be treated for their mental illness just as they should be treated for their diabetes or hypertension.”

The full report is available at: 


The Treatment Advocacy Center is a national nonprofit organization dedicated to eliminating barriers to the timely and effective treatment of severe mental illnesses. The nonprofit promotes laws, policies and practices for the delivery of psychiatric care and supports the development of innovative treatments for and research into the causes of severe and persistent psychiatric illnesses, such as schizophrenia and bipolar disorder. The organization does not accept money from pharmaceutical companies. The American Psychiatric Association awarded the Treatment Advocacy Center its 2006 presidential commendation for "sustained extraordinary advocacy on behalf of the most vulnerable mentally ill patients who lack the insight to seek and continue effective care and benefit from assisted outpatient treatment.”


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