Real Mental Health Reform of the Criminal Justice System?

Michigan’s State House at Night

Michigan House Speaker Tom Leonard recently established a bipartisan task force, called Michigan C.A.R.E.S, to work on Mental Health reform across Michigan and especially across Michigan’s Criminal Justice System.

Representative Klint Kesto (R) and Hank Vaupel (R) are the co-chairs of the task force and they have opened up an online space for public comment and also released a public meeting schedule for the task force.

While the task force has a wider mandate, my area of concern is mental health in jails and prisons (so I will limit my comments to only reforms in the area of incarceration).

I have been writing about mental health reform in Michigan’s jails and prisons for over a year now (usually using the vehicle of my recaps of the television show Orange Is the New Black). Also, I am a formerly incarcerated person.

After reading all of the publically available documentation, I have a few concerns (not much attention has been provided in the documentation about possible mental health reforms inside Michigan’s prisons and jails).

The Problem: Jails and Prisons have become Michigan’s de facto ‘treatment’ facilities (and they don’t often treat)

Is This What We Stand For?

According to the Bureau of Justice Statistics, 56% of state prisoners have mental health needs but only one of every three prison inmates and one of every six jail inmates have received treatment during their incarceration.

If you look at the most recent assessment of treatment in Michigan prisons, the statistics are even more dismal:

“According to these measures, 20.1% of men and 24.8% of women in Michigan prisons have mental health symptoms and 16.5% and 28.9%, respectively, are receiving mental health services. However, when compared with the MDOC’s mental health records, 65.0% of prisoners who are experiencing mental health symptoms are not currently receiving any psychiatric services. This percentage is relatively insensitive to different methods or higher severity thresholds for determining mental health services. We also found that 40% of those we determined to be in current need of substance abuse treatment, those with prior use of illegal substances, misuse of prescription medications, and/or prior alcohol abuse, and scheduled to be released within six months were not receiving these services.”

To be even more frank, the authors of the survey put these numbers in more direct context:

“Alternately computed, if we make the broad assumption that all of the 8,115 prisoners who have a MDOC MH diagnosis would have been detected by our assessment if their symptoms were not controlled, then MDOC is not serving 6,312 out of 14,427 prisoners (all prisoners except the 33,461 without either a study or MDOC MH diagnosis), or 43.7% of the prisoners statewide.”

And in Michigan’s jails (as I know from my personal experience at the Macomb County Jail) the “treatment” could be called barbaric as opposed to therapeutic.

In my short time housed in the mental health block I met people who had been ‘treated’ with only drugs, talk therapy, and 23-hour a day solitary confinement for over a year. As the medical profession has concluded, solitary confinement for someone who is mentally ill can be virtually indistinguishable from torture.

A recent independent assessment of the Macomb County Jail concluded:

“The Macomb County Jail, like many jails, is challenged by the need to care for an increasing number of mentally ill inmates. In Macomb County, the already difficult task of providing quality care and coordinated case management is made all the more difficult by an overcrowded jail mental health unit (with some inmates housed in booking due to lack of space); impediments to information collection and sharing (The Forensic Center will not accept jail inmate information without a Release of Information; the rotation of jail deputies in and out of the mental health unit; and the lack of full-service coverage.”

And before you claim this is impossible, I myself, spent a few days (misdiagnosed because of over-simple screening questions) in solitary in the Macomb County jail. Solitary Confinement, sadly, is not an abnormal way to treat the mentally ill in Michigan’s jails and prisons.

I also want to emphasize that the problem is not only about deficits in care but also in regards to provision of the appropriate care necessary for each inmate and also for more significant access to research-based programs and treatment for addiction (three quarters of state prisoners with mental illness reported co-occurring substance abuse dependence).

An independent study of Michigan’s treatment of mentally ill people in prison concluded that:

“Substance abuse services (therapy code GD) reflect only 5.6% of the total MH services provided by MDOC, according to the HMIS database. It is possible that prisoners may be receiving informal help with substance abuse issues, perhaps through Alcoholic Anonymous groups offered within the facility. These are not necessarily professional services, however, and are not being coordinated or provided by MDOC, and therefore not measured in our study.”

It is morally wrong to treat people who are mentally ill through incarceration and it is also dangerous.

Cook County Sherriff Tom Dart perhaps put our current mental health incarceration crisis best when he argued:

“Ten times more mentally ill people are housed in America’s jails and prisons than in mental health hospitals.”

I ask our elected officials to explain to me under what moral authority to they continue to look the other way while some of the people most in need of care are continuously overlooked?

The Solution: Invest In Evidence-Based Mental Health Training and Treatment

Every Incarcerated Person in Michigan Visits Jackson

In my opinion, it is critically important that Michigan engage in serious mental health reform in it’s prisons and jails. Here are my evidence-based suggestions for reform:

Humanize ‘Detainees’ and deliver transparency in place of opacity

The Best Practices template released by the Cook County Jail emphasizes re-humanizing inmates and ensuring transparency by invited watchdogs IN jails and prisons (not keeping prisons treatment of the Mentally Ill out of sight and out of mind).

Pulitzer-Prize winning historian, and University of Michigan professor, Heather Ann Thompson often writes about the importance of prison transparency to ensuring meaningful reform. For instance, she argued that the long-standing opacity of prison has continuously reaffirmed a systemic bias in the public’s mind:

“But throughout American history, we’ve really hidden, at least, the institution of prisons, while we have made very public supposedly the archetypal prisoner. So we’ve seen the prisoner on a chain gang, or we’ve seen the prisoner working beside the road, picking up trash, often marked by a certain uniform or a certain way in which we know that they must have done something wrong, but we have absolutely no sense of, what are these institutions they return to? And we really never have. And so there have been various legal fights to try to get the public aware of what’s happening inside, primarily because what’s happening is brutal, and, indeed, the public needs to know that, because that’s what they’re paying for, right? It’s not just a confining of somebody, but often an abuse of someone, a torture of someone.”

As long as our prisons and jails remain a black box, it will be hard to ensure that best practices are being implemented (not just funded).

As long as our prisons and jails remain a black box, it is impossible to ensure that our mentally ill prisoner bodies aren’t being used to perpetuate a system of neglect and abuse.

It is very hard to find up to date information on the practices in place in prisons and jails in Michigan and part of that is because there is not much transparency as to how Michigan addresses the mental health needs of its inmates.

2. Provide advanced mental health training to all Law Enforcement and Corrections personnel

The Cook County report (cited above) explains the importance of mental health training for personnel:

“With jails bursting at the seams with mentally ill inmates, the capacity for tension and unpredictable behavior increases in turn. And the transient nature of jail populations means a disproportionate number of inmates are fresh off the streets, where they may not have been taking the medication they desperately need. All jails are forced to manage inmates who demonstrate actively psychotic behavior, which requires officers who are well trained in how to diffuse situations through words in lieu of force. Numerous counties have had to make multi-million dollar payouts as a result of officers utilizing excessive force on mentally ill inmates, which potentially could have been avoided through an investment in CIT training.”

There are also moral arguments for why we should ensure that the people with the power of life and death over inmates should also understand the impact their decisions can have on those inmates. Way too often, as I mentioned above, treatment for the mentally ill means a steady diet of drugs and a long-term stay in solitary confinement. There is no excuse for returning someone to society (and over 90% of inmates will return to society) in worse mental shape than when they entered.

3. Redefine What Treatment Means

If you do the research, you will see many official documents talking about how much money is going to mental health treatment or how mental health treatment is organized in the prison system but very few documents about what kind of treatment is being provided or the quality of the people providing it.

I can tell you from experience (and with backing from the studies that I have already cited) that Jails and Prisons are primarily concerned with preventing suicides and not with treating prisoners. A meta-analysis of prison mental health care describes the problem I am describing like this:

“It was expected that the results of this review would provide clinicians with empirical guidance on which to develop or base their services; however, results of this review reinforced the conclusion that “treatment outcome research on mentally ill offenders specifically is almost nonexistent” (Rice & Harris, 1997, p. 164), and “are as scarce now as they were 30 years ago” Too few programs are being developed and too few promising programs are being tested with the rigor that would yield the proof needed to label them as evidence based” (Snyder, 2007, p. 6). Given the prevalence of OMI in the criminal justice system (approximately 1,000,000 individuals) as previously described, it is surprising that so few studies (n = 26) meet the scientific inclusion criteria to effectively examine the effects of services for OMI. The almost complete absence of randomized controlled clinical trials is particularly disappointing as clinicians treating OMI are without sufficient efficacy or effectiveness data on which to base their practices. Unfortunately, the results of this review provided less additional data than expected. Nevertheless, two therapeutic elements, admission policies and use of homework, were identified as contributing to enhanced therapeutic outcomes.”

Providing treatment is not the same as ensuring that the treatment that you provide is based on evidence or on best practices.

Providing treatment is not the same as ensuring that the people delivering treatment are good therapists.

Providing treatment is not the same as ensuring that the people delivering the treatment are qualified and trained for the kind of work they will be facing in prisons and jails.

Providing treatment, to be effective, must include evidence-based programs for recovery from addiction and other co-occurring problems. We know what to do but we aren’t doing it:

“The components of quality, comprehensive mental health care in prison are well known. They include systematic screening and evaluation for mental illness; mechanisms to provide prisoners with prompt access to mental health personnel and services; mental health treatment that includes a range of appropriate therapeutic interventions including, but not limited to, appropriate medication; a spectrum of levels of care including acute inpatient care and hospitalization, long-term intermediate care programs, and outpatient care; a sufficient number of qualified mental health professionals to develop individualized treatment plans and to implement such plans for all prisoners suffering from serious mental disorders; maintenance of adequate and confidential clinical records and the use of such records to ensure continuity of care as prisoners are transferred from jail to prison and between prisons; suicide prevention protocols for identifying and treating suicidal prisoners; and discharge planning that will provide mentally-ill prisoners with access to needed mental health and other support services upon their release from prison. Peer review and quality assurance programs help ensure that proper policies on paper are translated into practice inside the prisons.”

In addition, we are facing massive treatment deficits, many Michigan prisoners are kept on waiting lists for years prior to getting programming that is a quid pro quo for parole. I myself was denied parole twice, despite zero disciplinary actions in my three years of prison, solely because I had not completed programming that the MDOC had not suggested but that the parole board considered mandatory.

Some will argue that per-prisoner costs are already too high to invest in more programming and treatment, but I would suggest that per-prisoner costs are the wrong metric to use for delaying reform:

First, recent research proves that the major drivers of prison costs in Michigan are personnel and facilities not per-prisoner costs. Second, as I recently discussed with sociology professor and Criminal Justice Reform author John Pfaff, it is rational and even necessary that as facilities close down, per-prisoner costs should go up.

We have just spent several decades cutting services and programs because of the desire to be ‘tough on crime and now in order to ensure we can continue to close facilities and reduce our prison populations even further, we will need to help formerly incarcerated people reintegrate in the best shape possible to prevent recidivism and protect the returning prisoners and society from failure. This is still a problem that the MDOC, and the Michigan House, and Senate are not addressing.

Finally, the cost of each denial of parole is much higher than the costs of treatment. Generally, 12–15 prisoners are involved in each programming group while the cost of each denial of parole is approximately $35,000 per inmate. The cost of a therapist (who could cover multiple groups at a time) is far less than the cost of failure to provide programming (do the math, assuming a few people don’t complete programming in each group, it comes to millions in long term savings per therapist).

Nothing that I saw or experienced in prison offended my moral sensibilities more than how Michigan’s jail and prison systems treated the mentally ill. There is a strong safety and cost-based argument to be made for providing better mental health care for mentally ill and addicted inmates but, at the end of the day, no society that calls itself civilized (or a city on a hill) should treat it’s most vulnerable with such utter and callous disregard.

So I will conclude with a quote about what being in prison does to people in Michigan afflicted with mental illness and a quote about the scope of the crisis and needs:

“In addition, reports suggest that stressors experienced during imprisonment are likely to exacerbate pre-existing mental illness. Psychological stressors include the thought of lifetime confinement, separation from one’s family, and the fear of victimization.”

And finally, as a 2005 assessment of the MDOC by Doctor Terry Kuper’s M.D. M.S.P put it:

The adequacy of mental health services cannot be measured solely in terms of staffing levels or the number of prisoners who receive mental health treatment or are placed in Suicide Observation, with or without medications. Adequate mental health treatment requires the availability of a trained clinician to develop a trusting relationship with a patient in a setting that permits privacy, where confidentiality is respected so that very personal themes can be explored and worked through. Adequate mental health treatment requires a variety of treatment modalities, including but not limited to crisis intervention; psychotropic medications as needed; the availability of a certain number of group activities such as group therapy, psychoeducational groups, facilitated socialization or recreational activities, and psychiatric rehabilitation groups that involve psychoeducational programs, training in the skills of daily living and medication compliance; admission to an acute psychiatric hospital as needed; social work outreach to family members as needed; and after-care planning so that the disturbed individual is not returned to the environment that caused a breakdown but rather is provided with the ongoing care and social supports needed to sustain his mental health. For example, placement in a cold observation cell with no clothing nor other amenities and a daily cell-front chat with a mental health worker, followed by return to a segregation cell with nothing but brief cell-front follow-up assessments, by no means constitutes adequate treatment for depression with a suicidal crisis.

We need to do better for Michigan’s mentally ill (many of whom are in our prisons and jails). Thanks for your attention.

Josh is a 100% reader-funded blogger and freelance writer. Please consider following him on Twitter, throwing a tip into his hat on Patreon, or adding his blog OnPirateSatellite to your feeds. Support writing on platforms like Medium that don’t have pop-ups or bloatware!