Work Sample

Addressing Mental Health in U.S. State Prisons

Click here for the PDF version: JLC Research Proposal

Mental illness in prisons has been a pervasive issue that has ravaged the United States’ prison system for decades. Both men and women that enter the prison system endure conditions that exacerbate the symptoms associated with mental illness. State prisons in the U.S. house among the highest number of inmates with preexisting mental health conditions. The mistreatment of inmates with mental health problems stems from the state’s desire to reduce their annual expenses, specifically with regards to healthcare, combined with the consequences associated with the overcrowding of prisons. These factors ultimately contribute to a lack of diagnosis and treatment of inmates with psychiatric conditions. The synthesis of social stigmas derived from living with a mental illness and being currently, or formerly, incarcerated diminishes an individual’s ability to survive within the prison system and consequently the outside world. Therefore, the following question can be posited: “What factors in the United States’ state prison system contribute to the provision of inadequate health care services for inmates with preexisting mental health conditions?” This question can be addressed through both secondary analysis as well as the conduction of a purposive study comparing a set of state prisons with adequate health care versus without. This study will allow for a deeper understanding of how individuals with preexisting mental health conditions are disproportionately affected by the criminal justice system as well as the adverse effects that lack of treatment and healthcare can have on an individual with a mental illness.

There are a multitude of reasons as to why such a topic is important to study and consequently understand. While little research has been conducted in answering the question of why inmates with mental illness are negatively impacted by lack of funding and overcrowding, there are statistics confirming the prevalence and severity of mental illness in state prisons. Additionally, prisons aren’t held accountable for the lack of provision of mental health services and are causing severe harm to inmates suffering from the implications of psychiatric conditions. This is largely problematic because those with mental illness must be provided with treatment and care. Therefore, it is important to understand why those with mental illness are in prisons at such disproportionate rates and what can be done to hold prisons accountable and provide treatment to those that need it. In conducting this research, the major issues to be addressed are the stigmatization faced by inmates and individuals with mental illness, the inaccessibility of quality healthcare while incarcerated, and overall treatment for those living with mental illness.

Today, the U.S. houses 5% of the world’s population, but 25% of the world’s prison population, making the U.S. the largest prison system in the world. In addition, 50% of said inmates suffer from mental illness (Hoke, 2015, p. 36). Included in these statistics are those suffering from psychotic disorders, major depression, antisocial personality disorder, anxiety disorders, and distress associated with trauma among others. The maltreatment of inmates suffering from mental illness stems from the closing of public mental health hospitals in the 1960s due to the provision of antipsychotic medications, such as Olanzapine, and the movement of moving patients into safer and more community-based facilities. Twenty years later, the war on drugs led to an increase in arrests related to drug usage and sales, resulting in the increase in proportion of inmates with psychiatric disorders and substance abuse issues (Hoke, 2015, p. 37).

With the rise of individuals with mental illness in prisons came federal legislation that sought to protect their rights. One of the Supreme Court cases that served as the backbone of providing prisoners with access to medical treatment was Estelle v. Gamble, which concluded that prisoners are entitled to access to care for diagnosis and treatment, professional medical judgement, and administration of treatment via a physician. Seven years later, the Civil Rights of Institutionalized Person Act requires institutions to provide medical staff and mental health professionals to determine the needs of prisoners. While these two pieces of legislation made large strides in ensuring inmate’s access to medical services, many institutions are continuously found guilty of requiring copays, providing incorrect administration of medications, stopping of medications entirely, and delay in obtaining medications among others (Nowotny, 2017). 

After the passing of legislation protecting the rights of prisoners was enacted, state institutions sought to meet the federally-mandated requirement by spending the least amount of money as possible. As a result, prisons began to utilize managed care organizations (MCOs). MCOs are healthcare providers that offer healthcare plans that compete with each other to provide the lowest prices. Those who run prisons are incentivized to choose the cheapest option as inmates have no choice regarding their healthcare plan, therefore they must use what they are provided with or go without treatment or care (Robbins, 1999, p. 197). Another tool used by prisons to increase their profit and reduce their spending is the adoption of the flat-fee model. This model dictates that a company (in this case the institution) is provided with a flat-rate amount of money for the prison to spend and what isn’t spent is turned into a profit. Consequently, prisons are further incentivized to spend less money on providing healthcare services to their inmates and ultimately prevents the effective and adequate provision of medical treatment to inmates that require it. In order to combat this, Spicer v. Williamson established that prisons are required to supply healthcare to inmates because incarceration deprives them of the ability to attain healthcare services outside the confines of the prison (Bondurant, 2013, p. 410).

A multitude of research studies have been conducted in order to understand the significance of individuals in prison with mental illness and the extent to which it goes unaddressed. Prior to analyzing the extent of which inmates suffer at disproportionate rates of mental illness, it is vital to understand the drastic increase of the prison population over the past decades that has ultimately contributed to overcrowding, one of the leading causes of the exacerbated conditions associated with mental illness.  In 2006, it was discovered that more than 170,000 prisoners in California were held in facilities intended for 80,000. In 2011, research indicated that prison population in California had risen beyond 200% of their capacity. This is not a trend only present in California, but across the U.S. Over the past 40 years, prison populations in the U.S. have risen by 600%, with 1% of the population having been incarcerated at one point in their lives. From overcrowding stems a multitude of issues that negatively impact the quality of life of prisoners. Of them are lack of physical space to fit inmates and housing, poor sanitation, limited resources, higher rates of communicable illness, and higher suicide rates among others (Applebaum, 2011). Coupled with a diminished capacity to abide by the rules of prison life and consequent utilization of solitary confinement to punish inmates, those in prisons are unable to cope with their mental illness due to a lack of provision of necessary treatment.

One of the most significant studies that discussed the prevalence of mental illness in state prisons was conducted by the U.S. Department of Justice. In 2005, it was found that 56% of state inmates (705,600 people) suffered from a mental health problem, 13% of state inmates endured homelessness and foster care, and 70% of state inmates face lower rates of employment and higher rates of illegal income. Overall, one-third of state prisoners who had mental health problems had received treatment since admission (James and Glaze, 2006). This means that the vast majority that require treatment received none. A study released by the Massachusetts state prison system revealed statistics that coincided with the results shared by the U.S. Department of Justice. The study revealed that 56.2% of state inmates have reported or knowledge of mental health problems that require treatment. Specifically, 21% were afflicted with mania, 26% with major depression, and 11% with at least one psychotic symptom (Fisher et al., 2014, p. 813). As evident in both of these studies, mental illness is a very prominent issue within the criminal justice system, making access to quality health care and mental health services a necessity.

The primary theoretical framework that has been applied to the study of the implementation of healthcare in prisons is the health promoting prisons theory as well as the ecological model of public health. The theory of health promoting prisons is mainly driven by the idea that an approach that focuses on each individual prison serves in the best interest of the stakeholders involved because it allows for the concentration to be directed towards creating an environment that promotes overall health and well-being. Therefore, it is clear that the issues that inmates with mental illness face in prison can be analyzed within the context of the ecological model of public health. This model is rooted in the idea that an institution is shaped by the complex interactions among factors such as environmental, organizational, genetic, and behavioral. These factors work together to create a system that can be analyzed within its capability to introduce and maintain change and health, and in this case, rehabilitate prisoners. Both the health promoting prisons theory and the ecological model are applicable within the context of this study because individuals living with mental illness make up a large portion of the prison population (Baybutt and Chemlal, 2016, p. 68). Therefore, prisons are obligated to promote and protect their health. 

While such research and studies as mentioned above have made great strides towards understanding the relationship between mental illness and state prison inmates, there is much left to be understood regarding the impact of the prison industrial complex on the individual. More specifically, previously conducted research has failed to address the question of what the far-reaching consequences are of lack of treatment and care in state prisons. Current research disregards the effects that the prison environment has on mentally ill individuals aside from recidivism. It also fails to account for and address the individual impacts and post-release effects of said mistreatment and what this means for inmates once they are outside of the bounds of the criminal justice system.

Analyzing data previously collected on statistics of inmates with mental health illnesses is key in answering the aforementioned research question. Gathering information such as the type of condition, age and gender of the individual, the severity of the crime committed, and a previous record among others is vital in understanding what the risk factors are of such mental illnesses and what groups of people are disproportionately affected by the inadequate provision of mental healthcare services in state prisons. Additionally, it is important to analyze the historical context of the treatment of individuals with mental illnesses to understand why they are in prisons today and how their conditions are being treated. Conducting personal research would also be beneficial, for example, analyzing a prison in a state with adequate mental health resources and treatment in contrast with one with inadequate resources. Doing so would allow for the comparison of the results through categorizing them based on violent and nonviolent offenses and types of mental health conditions, among others. This would provide a strong indication as to the impact of the adequacy of mental health services on inmates suffering from psychiatric conditions. Such a course of action, though productive, may prove difficult due to privacy laws that are currently in place, especially because inmates and those with mental illnesses are considered to be vulnerable populations.

Regarding methodology, both qualitative and quantitative data collection methods will be utilized. Qualitative data collection will include data measuring the types of mental illness, what kinds of treatments are prescribed, and the types of healthcare systems currently in place in state prisons. Quantitative data collection will include the number of inmates with preexisting mental health conditions, how many of these individuals recidivate, and the percentage of given disorders in state prisons. As mentioned above, a portion of the data to be collected will be secondary such as data collection from published statistics from the Bureau of Justice Statistics (BJS) to give context to the number of inmates afflicted with a psychiatric condition. Additionally, understanding past treatment measures received by people with mental illness, the history of state prisons, and the types of healthcare systems implemented will constitute further secondary analysis. Furthermore, a longitudinal study and comparative analysis would be essential as this would provide context to the benefits of receiving treatment versus being left untreated and what the correlation is between types of treatment, if any, and the impact on the recidivism rate. This would be done by selecting two states, one that is known to provide adequate treatment for mental illnesses in state prisons and one that is inadequate. Within these states, the population of inmates with psychiatric conditions would be analyzed in terms of their conditions and treatment options. The study would be controlled by types of offenses (violent and non-violent) and would provide a deeper understanding of the impact of effective treatment on the recidivism rate of inmates with preexisting mental health conditions. In this study, the population would be inmates with preexisting mental health conditions and the unit of analysis would be inmates.

The sampling methodology would be purposive, as those who participate in the study would be selected based on their ability to produce useful information and results as the research focuses on a very specific portion of the prison population. Within the context of this research study, inmates with preexisting mental health conditions would be selected in order to obtain information and data that confirms or refutes the posited notion that overcrowding and lack of funding have a negative impact on inmates with psychiatric illnesses in state prisons. With regards to internal validity, history may present itself as a problem as the subjects are a vulnerable population and may have had a difficult past as a result of their condition, and their mental capacity may change throughout the course of the study. Mortality is another challenge as inmates can leave the system or die in prison as well as reactivity, as inmates may change their behavior, specifically the presentation of symptoms, if they know they are being studied.  Additionally, selection may be difficult because all inmates will have varying degrees and symptoms depending on their mental illness. This will make it difficult to compare individuals and generalize findings since all inmates will have different symptoms and experiences. With regards to external validity, population validity, as mentioned prior, may be difficult as a researcher can’t generalize findings because all mental illnesses aren’t the same and have varying effects on the body.

Conceptualization refers to the idea of making imprecise notions more specific in order to form a working definition. In the context of this research study, conceptualizing managed-care organizations, mental illness, and overcrowding will be useful to create a better understanding of what the study seeks to analyze. Potentially most importantly, understand the different types of psychiatric illnesses to be included in the study such as the underlying causes, symptoms, and treatment. This will also enable individuals reading the study to better perceive the results because they will understand the working definitions of the terms used. Conceptualization directly relates to the idea of operationalization, which refers to the idea of taking abstract concepts and converting them into measurable variables. In this study, preexisting mental health conditions can be understood as treatment received (number and types of medication, therapy, psychiatric services, etc), overcrowding as the number of inmates in a given institution, and the effectiveness of state prisons can be measured in the availability and quality of the provision of different treatment measures and access to healthcare. For example, treatment can be deemed effective if there are psychiatric practitioners and medical doctors that are qualified and accessible to inmates, medications are provided in a timely and consistent manner, and the health care providers utilized by prisons are held to a higher standard of providing care. When conducting this research, the independent variable is defined as access to treatment if there is the presence of a mental health condition and the dependent variable is defined as the influence of mental illness on the likelihood to offend. However, a moderating variable is present, which can be defined as a variable that influences the direction and/or strength of the relationship between the independent and dependent variable. In this study, the moderator variable is a lack of access to healthcare and effective treatment. This has been found to have an affect on an individual’s likelihood to commit crime if they have a psychiatric condition. Ultimately, this can be characterized as nominal measurement as such attributes are merely different, for example, classifying inmates based on whether or not they have a mental illness, if they have access to healthcare, and if they reside in a prison that suffers from the ramifications of overcrowding and lack of funding.

While current research supports the idea that lack of funding and overcrowding can negatively impact the health of prisoners, there are other plausible arguments that can be made with regards to other factors that have a prominent adverse effect on the mental health of inmates. An example of this would be the ability to access qualified medical professionals that are willing to work within state prisons. Due to reasons related to inadequate pay and fear for safety, medical professionals may be unwilling to work within a state prison. Therefore, this can contribute to a lack of effective treatment as prisons are forced to hire individuals that may not have as much experience or as qualified of credentials as they would prefer. This idea does not pose as strong of an argument as lack of funding and overcrowding because it is not a widely proven fact that all medical employees within prisons are underqualified. Also, this doesn’t correlate to or play as prominent of a role as the other two factors in negatively impacting the presentation of symptoms.

When referencing secondary data to supplement the analysis, there are a multitude of strong resources, yet the most prominent is a report created by the Bureau of Justice Statistics (BJS) titled Mental Health Problems of Prison and Jail Inmates. The report contained statistics regarding the prevalence of a variety of mental health conditions among inmates and the far reaching implications of such including homelessness, employment, rates of illegal income, and rates of past physical and mental abuse as mentioned prior (James and Glaze, 2006). Such information is vital in understanding potential underlying causative factors or features that can contribute to crime and why the majority of the prison potential has a mental illness.

In addition to analyzing secondary data, a comparative analysis will also be conducted to provide context to the benefits of receiving treatment for mental health conditions versus going untreated. When conducting this study, New Hampshire and Texas have been selected as the two states of analysis. Based on a report conducted by Mental Health American, New Hampshire has been deemed one of the few states that has been recognized for providing adequate access to treatment for mental health conditions while Texas has been deemed one of the worst. These states were selected by being grouped and listed based on whether or not they provided adequate access to health care and a random number generator provided a number, which was used to select a state from the list to ensure randomization. With regards to the experiment itself, five prisons from each state will be selected. Within these five prisons, 100 inmates will be selected that have a known preexisting mental health condition and 100 without a reported illness to serve as the control group. Then, the crimes will be classified as non-violent and violent and by specific mental health condition to better understand the adverse effects that lack of treatment can have based on type of condition and offense.

Through such research methods, I seek to answer the aforementioned research question by positing that overcrowding and lack of funding have lasting and far-reaching effects on the presentation of symptoms of preexisting mental health conditions of inmates in state prisons. Overcrowding contributes to the worsening of the conditions associated with mental health diagnoses because a lack of personal space, reduction of available resources, and crowded living conditions can exacerbate the presentation of symptoms related to different diagnoses. A lack of funding also plays a prominent role because prisons profit off of the money that goes unspent, therefore they are incentivized to choose the cheapest MCO since inmates have no other options regarding healthcare while they are incarcerated. Using secondary data analysis coupled with individualized research, this study intends to understand the effects of overcrowding and lack of funding and how the two factors negatively impact the mental health of inmates in state prisons.

When conducting research, a variety of limitations present themselves throughout the process. The most prominent limitation being the lack of prior research. This is a hindrance in the research process because there is no background and contextual information that’s available. Another is measuring the collected data as it is difficult to both define and measure the severity of a specific illness. This relates to another limitation which is that there may be people selected for the control group that either have an unreported mental illness or a mental illness that developed in prison, which would greatly affect the outcome of the study. Lastly is if an inmate received treatment prior to incarceration and the idea that different mental illnesses have differing effects, as this would also skew the results of the study.

Through such research methods, the expected results based on prior research are that there are high rates of mental illness in state prisons and such conditions are exacerbated by overcrowding and lack of funding. High rates of mental health conditions in prisons is evident in the statistical reports posted by the BJS. Additionally, overcrowding, lack of funding, and the unwillingness to allocate resources to those with psychiatric conditions in state prisons have been suggested and proven in a variety of studies and peer-reviewed articles. Overall, these factors have a negative impact on inmates that struggle with mental illness. Results that would disconfirm my hypothesis would be that inmates in state prisons don’t suffer disproportionately from mental illness and that overcrowding and lack of funding have no causative effect on the preexisting mental health conditions of inmates. If the research to be conducted was to confirm my hypothesis, much insight would be provided. First and foremost, more context would be provided as to why there are such high rates of mental illness in inmates in state prisons, opening the door for more studies to be conducted on the topic. Also, this discovery would allow for steps to be made towards reducing the negative implications of prison life on inmates with known preexisting mental health conditions and improving their quality of life. Examples of this include, but aren’t limited to, allocation of funding, reduction in the prison population, and improving the physical living conditions of prisons in the U.S. among other factors. Doing so would raise awareness to the issue and hopefully lead to reform that would improve the care of those with mental illness in prison by holding prisons accountable for the their lack of treatment for inmates with psychiatric conditions.

Conducting a study such as this one, as it is the first of its kind, allows for a deeper understanding of the implications that overcrowding and lack of funding have on inmates suffering from mental illness. More specifically, this study will open the door to more research that will better enable society to learn how to provide inmates with effective treatment and ensure that effective treatment is administered. Using both secondary analysis and conducting a comparative study are key in understanding this prevalent issue because it shows what effective care looks like and how it positively impacts inmates versus the damage a lack of care has on said inmates. The secondary analysis furthers this by providing contextual information such as age, gender, adverse life experiences, and prior history among other factors. A study such as this shows the stark difference that the provision of effective and proper treatment can make and ultimately lead to reform of the criminal justice system as well as the healthcare system. While society is aware of the prevalence of mental illness in the criminal justice system, they aren’t as cognisant of overcrowding and the damage done by lack of funding. A larger question is that of which isn’t known regarding how these two factors are contributing to the worsening of symptoms associated with mental illness in prisons. Therefore, this study seeks to answer this question as well as destigmatize and provide care to those who need it.

References

Appelbaum, P. S. (2011). Law & Psychiatry: Lost in the Crowd: Prison Mental Health Care, 

Overcrowding, and the Courts. Psychiatric Services, 62(10). doi:10.1176/appi.ps.62.10.1121

Baybutt, M., & Chemlal, K. (2016). Health-promoting prisons: theory to practice. Global Health 

Promotion, 23(1_suppl), 66–74. https://doi.org/10.1177/1757975915614182

Bondurant, B. (2013). The privatization of prisons and prisoner healthcare: Addressing the extent 

of prisoners’ right to healthcare. New England Journal on Criminal and Civil Confinement 39(2), 407-426.

Fisher, W. H., Hartwell, S. W., Deng, X., Pinals, D. A., Fulwiler, C., & Roy-Bujnowski, K. 

(2014). Recidivism Among Released State Prison Inmates Who Received Mental Health Treatment While Incarcerated. Crime & Delinquency, 60(6), 811–832. https://doi.org/10.1177/0011128714541204

Hoke, Samantha, MSN,P.M.H.N.P.-B.C.,R.N. (2015). Mental illness and prisoners: Concerns for 

communities and healthcare providers. Online Journal of Issues in Nursing, 20(1), 36-45. Retrieved from http://proxyau.wrlc.org/login?url=https://search.proquest.com/docview/1710043952?accountid=8285

James, D. J. & Glaze, L.E. U.S. Department of Justice. (2006). Mental Health Problems of 

Prison and Jail Inmates (NCJ 213600). Washington, D.C.: Bureau of Justice Statistics

Nowotny, K. M. (2017). Health care needs and service use among male prison inmates in the 

United States: A multi-level behavioral model of prison health service utilization. Health & Justice, 5(9), 1-13. doi:10.1186/s40352-017-0052-3

Robbins, I. (1999). Managed Health Care in Prisons as Cruel and Unusual Punishment. The 

Journal of Criminal Law and Criminology (1973-), 90(1), 195-238. doi:10.2307/1144165


Context

The above work constituted as a final paper submission for the course Intro to Justice Research in the Spring of 2019. The course is centered around practicing both the research and writing skills and techniques that are vital in the field of criminal justice research. As a final product of the material learned, I produced a research proposal containing a literature review, theoretical discussion, methodology, and analysis regarding the implementation of health care resources for incarcerated persons with preexisting mental health conditions in U.S. state prisons. More specifically, I discussed a potential study to be conducted to determine the effectiveness of currently used health care programs as well as their successes and limitations and next steps based on the findings of the proposed study.

Reflection

This paper is a direct example of the nexus of both of my majors. With a passion for both criminal justice and public health, the course provided me with the perfect opportunity to create a product that merges both of my career interests. More specifically, I have a strong desire to learn more about protecting inmates’ rights in prisons as well as the field of mental health. Today, the criminal justice system is recognized as widely dysfunctional and abusive and therefore is unable to ensure liberty and justice for all as evident through mass incarceration, mandatory minimums, etc. This paper allowed me the opportunity to explore the cross-sections of criminal justice and public health by researching and analyzing existing and potential methods for ensuring mental health treatment for inmates in state prisons. Through both the course, as well as the months of research and thought, put into developing this research proposal, I have further grown my interest and passion for advocacy, education, and research in both criminal justice and public health.