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Meeting the needs of mentally ill offenders: inmate service utilization.

In the past two decades, the criminal justice system has become the de facto warehouse for individuals with mental illness and other mental health issues. (1) In fact, in a 1995 editorial in the American Journal of Public Health, E. Fuller Torrey estimated that approximately twice as many individuals with mental illnesses were in the criminal justice system than in state psychiatric facilities. The availability and accessibility of mental health programs and services provides for safe and manageable environments throughout the criminal justice system, (2) as a 1999 Bureau of Justice Statistics report estimated that approximately 16 percent of jail inmates, 16 percent of state prison inmates, 7 percent of federal prison inmates and 16 percent of probationers suffer from severe and persistent mental illnesses (i.e., psychotic and mood psychiatric disorders). Moreover, approximately 40 percent to 80 percent of inmates have antisocial personality disorder (i.e., history of violating the rights and welfare of others) and/or a history of a substance use disorder. (3)

In addition, studies have consistently identified higher rates of mental illness among inmates in prison or jails than among people in the community, with prisons housing more inmates with mental illness than jails. (4) The prevalence rates reported here are limited to severe mental illnesses and do not consider other mental health conditions, such as mental retardation, impulse-control disorders, attention-deficit/hyperactivity disorder, or other clinical problems. (5) Nevertheless, taken together, the prevalence rates of severe and persistent mental illnesses and other psychiatric or substance use disorders underscore the burden inherited by the criminal justice system, and correctional facilities in particular, to meet the mental health needs of inmates.

Responding to the rising number of inmates suffering from a severe mental illness, the correctional system has increased the number of mental health providers; however, these staffing increases have not been proportionate to increases in the inmate prison population or the increasing number of mentally ill offenders incarcerated in U.S. jails and prisons. (6) Nevertheless, mental health professionals are responsible for providing a myriad of services inside the walls of today's correctional facilities.

Types of Mental Health Programs Available to Inmates

A variety of services are offered to meet the mental health needs of inmates in U.S. jails and prisons today. These services include crisis intervention and management (e.g., suicide, dangerousness and acute psychosis), psychotherapy (individual and group), psychoeducational programs (e.g., prerelease programs, anger management programs), specialized treatment programs (e.g., sex offender programs, cognitive restructuring or criminal thinking programs) and substance abuse programs. (7) These services have historically been considered from one of two perspectives: general mental health treatment (services aimed at symptom reduction, adjustment difficulties and maintaining psychiatric stability) or offender rehabilitation (services aimed at reducing criminal behavior and subsequent recidivism).

More recently, however, in the Correctional Mental Health Handbook, (8) a conceptual model of correctional mental health treatment delivery in jails and prisons was proposed that incorporated a hierarchical approach to service provision based on levels of inmate needs. The premise of this model is that inmates have varying mental health needs, and these needs are best conceptualized as occurring at one of three levels. Level I services consist of basic mental health services and are available to all inmates. Basic mental health services include assessment and treatment services with the goal of identifying inmates with psychological or psychiatric problems and subsequently providing the necessary interventions to treat the disturbances, the handbook notes. Synonymous with a historical focus on general mental health services, Level I services are aimed at mental health stability and maintaining inmates in the least restrictive environment. Level II services include mental health services developed for specific groups of offenders. Examples of Level II services include substance abuse programs, sex offender programs, programs for youthful offenders and programs developed specifically for mentally ill offenders. Although Level II services supplement Level I services, the programs typically considered Level II services are geared more toward offender rehabilitation than psychiatric stabilization. The Correctional Mental Health Handbook states that Level III services are uniquely different from Level I or Level II services as these services implement psychosocial principals at a systemic level (i.e., institutional level) to facilitate inmate adaptive functioning. For example, classification systems, staff training and consultation, and mediation programs (inmate complaint mediation, hostage negotiation teams) are examples of services that rely on behavioral principles for inmate management. Level III services afford mental health providers a break from direct inmate contact, yet allows the mental health professional the opportunity to be helpful at the correctional organizational level.

Level I, II and III services afford inmates a variety of mental health services; however, little is known about issues related to service utilization. In other words, do inmates freely access these mental health services? What types of services and/or service providers do they prefer? Also, are there specific barriers limiting inmates' access to mental health services? These are important questions to consider if corrections is to effectively treat inmate mental health problems.

Inmate Perceptions of Mental Health Services and Service Utilization

Unfortunately, little is known about inmates' willingness to seek mental health services. Nevertheless, recent research is beginning to elucidate issues of service utilization and inmates' perceptions and attitudes toward mental health services. Inmates with prior mental health experiences that were perceived as helpful were more likely to seek additional mental health services while incarcerated. (9)

In "Inmate Perceptions of Mental Health Services," (10) a more recent study by Robert Morgan, Alicia Rozycki and Scott Wilson, inmates' experiences, perceptions and attitudes toward mental health services were investigated. The authors found that approximately one-third (31 percent) of inmates volunteered for mental health services at some time during their incarceration whereas approximately one-fifth (22 percent) were mandated to receive mental health services. When receiving services, inmates overwhelmingly preferred receiving services individually rather than in a group format and generally preferred psychologists or professional counselors as service providers, followed by psychiatrists, addiction counselors and social workers, respectively. Although inmates exhibited a preference for the existing format of services (i.e., receiving services individually rather than in a group format) and the type of mental health professional they see, they did not indicate a greater likelihood for seeking help with regard to any particular type of problem. In other words, the type of problems inmates experience rendered them no more or no less likely to seek mental health services. Thus, inmates who would likely request mental health services would do so regardless of the nature of the problem, and inmates who would not request mental health services would not do so regardless of the nature of the problem. This suggests, consistent with current treatment paradigms (11) and the provision of Level I services, that practitioners need to remain mental health generalists to meet the myriad of mental health needs presented by inmates.

Although the results of "Inmate Perceptions of Mental Health Services" provided useful information for mental health professionals developing and offering programs for inmates, as well as policy-makers determining funding for mental health services, much work remains to be done. For example, little is still known about inmates' perceptions and attitudes toward mental health services. Also, do inmates desire the types of services that research has indicated they need to function better within the correctional environment or after release? In other words, do inmates want "what works" with regard to the types of mental health services they receive? Do program requirements (or mandated therapy) impact inmates' attitudes toward mental health services and providers? Do program requirements impact inmates' likelihood for voluntarily seeking services at a later time? These are just a sample of the many questions that remain to be answered.

Inmate Utilization Of Mental Health Services

A disturbing discrepancy exists between inmate mental health needs and service use. (12) Specifically, although inmates with more severe mental health needs were more likely to receive mental health services than inmates with less severe mental health needs, 45 percent of inmates with the greatest mental health needs did not receive any mental health services in the year prior to the completion of the study. Additionally, women and white offenders suffering from psychosis or a mood disturbance (e.g., depression) were the most likely inmates to use mental health services. Men and minorities, on the other hand, were less likely to access mental health services during the course of the study.

Concerns of inmates using mental health services is an issue in both jails and prisons. According to a 1997 Bureau of Justice Statistics study of jails across the United States, most inmates do not use mental health services. In fact, the majority of jails in this survey reported current service use by 10 percent or less of all inmates. Furthermore, of women in a large metropolitan jail, nearly 75 percent who needed services did not receive any mental health interventions during their incarceration. (13) Similar patterns hold true in U.S. prisons. In 2001, BJS found that one in 10 state prison inmates received psychotherapy and one in eight received psychotropic medication. Notably, women used mental health services at considerably higher rates than men. Since admission to the correctional system, approximately 61 percent of prison inmates and 41 percent of jail inmates with severe and persistent mental illnesses and who are in greatest need of treatment used mental health services, BJS reported. Unfortunately, these findings indicate that mental health services are being used by a small minority of inmates with mental health problems. When the rates of mental illness are taken into consideration, the majority of inmates who have the greatest need for mental health services are going untreated.

These trends continue for inmates post-release. Within a year of being released from correctional facilities, 61 percent of ex-offenders with mental illness received some type of mental health services, although the services they received were not adequate to meet their complex treatment needs. (14) Moreover, in their 2004 Psychiatric Services article, "Slowing the Revolving Door: Community Reentry of Offenders with Mental Illness," Stephen Haimowitz and Paul Appelbaum reported that inmates with severe and persistent mental illnesses have limited access to effective mental health services while attempting to reenter the community after being released from prison. Collectively, research has demonstrated limited service use by inmates in general, and inmates with severe mental illnesses in particular, across jail and prison settings and upon release from prison. In addition, inmate service utilization rates are lowest among men and racial minorities, who make up the majority of incarcerated populations. Therefore, mental health professionals and correctional staff alike need to evaluate current service use and barriers to accessing mental health services in their jails and prisons.

Barriers to Inmate Service Utilization

It has been commonly speculated that inmates are reluctant to seek mental health services at best and harbor negative attitudes or perceptions toward mental health services at worst. (15) However, according to "Inmate Perceptions of Mental Health Services," inmates, in general, are less concerned about social pressures (e.g., labeled a "snitch," perceived as "weak") or institutional issues (e.g., information being used against them) than previously thought. Nevertheless, inmates housed in differing security levels did report different concerns impacting their willingness to seek mental health services. Notably, newly incarcerated inmates reported greater concern about social perceptions and institutional concerns for participating in mental health services. It was also found that inmates in maximum-security settings harbored greater concern about how information disclosed in the course of mental health treatment would be used against them compared with their peers in minimum-security facilities.

As noted previously, racial minorities are less likely to use mental health services than are white inmates. Also, among prison inmates in New Zealand, inmates' attitudes toward mental health services were better predictors of help-seeking intentions than psychological distress and treatment fearfulness, and prior use of mental health services predicted attitudes toward seeking help. (16) In another analysis of New Zealand inmates, psychological distress and stigma concerns were significant predictors of attitudes toward mental health services. (17) Therefore, inmates who have previously received mental health services and have been satisfied with prior mental health services are more likely to access services during their incarceration, and inmates who are in greater distress and who have fewer concerns about mental health stigmas are also more likely to access mental health services.

Improving Use of Inmate Services

The research on service use highlights several points of potential intervention to improve inmate access and use of mental health services. As discussed by Morgan et al. in "Inmate Perceptions of Mental Health Services," orientation procedures for newly admitted inmates in jails and prisons need to include information on the types of mental health services, how to access services, length of services and the various focuses of services (e.g., not only for mental illness but also for adjustment issues). In addition, during orientation procedures, newly incarcerated inmates' perceptions of mental health services, mental health stigmas and attitudes toward mental health services need to be assessed and corrected. (18)

Those inmates reporting a lack of prior contact with the mental health system or dissatisfaction with previous mental health services must receive additional education and information about the types, quality and benefits of available mental health services in order to increase the likelihood that they will access services during their incarceration. Newly incarcerated racial minorities would benefit from orientation procedures focusing on cultural barriers to accessing mental health services. Since newly incarcerated inmates may not self-refer for mental health services, Morgan et al. conclude that corrections officials must have a system in place to monitor and identify inmates who are in need of services. The researchers go on to say that throughout offenders' incarceration, confidentiality of services needs to be addressed, as these concerns tend to be prevalent among newly admitted inmates as well as inmates in maximum-security facilities. Additionally, inmates might benefit from periodic updates in available mental health services at their respective institutions, as well as receiving information about services upon arrival to a new correctional facility.

The correctional system has a responsibility to provide services to an ever-increasing number of inmates with significant mental health needs, including severe mental illnesses. Although correctional administrators and mental health professionals have responded by developing and offering a wide variety of mental health services, inmates are reluctant to access these services. Consequently, the majority of inmates with mental health needs are left untreated. In light of the fact that little is known about the specific barriers to mental health service utilization in correctional systems, those in the corrections field are behooved to further investigate potential barriers in their institutions and to implement measures to improve inmates' utilization of mental health services. Further work in improving access to and use of mental health services will result in more manageable inmates and safer correctional environments, not only for inmates but also for correctional officers, mental health professionals, support staff and administrators.


(1) See Kupers, T. 1999. Prison madness: The mental health crisis behind bars and what we must do about it. San Francisco: Jossey-Bass.

Torrey, E.F. 1997. Out of the shadows: Confronting America's mental illness crisis. New York: John Wiley & Sons.

(2) Cohen, F. and J. Dvoskin. 1992. Inmates with mental disorders: A guide to law and practice. Mental and Physical Disability Law Reporter, 16(4):462-470.

Ogloif, J., R. Roesch and S. Hart. 1994. Mental health services in jails and prisons: Legal, clinical and policy issues. Law and Psychology Review, 18(Spring):109-136.

(3) For example, Powell, T., J. Holt and K. Fondacaro. 1997. The prevalence of mental illness among inmates in a rural state. Law and Human Behavior, 21(4):427-438.

Teplin, L. 1994. Psychiatric and substance abuse among male urban jail detainees. American Journal of Public Health, 84(2):290-294.

(4) Abram, K. and L. Teplin. 1991. Co-occurring disorders among mentally ill jail detainees: Implications for public policy. American Psychologist, 46(10):1036-1045.

Diamond, P.M., E.W. Wang, C.E. Holzer III, C. Thomas and D.A. Crusar. 2001. The prevalence of mental illness in prison. Administration and Policy in Mental Health, 29(1):21-40.

Powell, T. et al. 1997.

(5) Pinta, E. 2001. The prevalence of serious mental disorders among U.S. prisoners. In Forensic mental health: Working with offenders with mental illness, eds. G. Landsberg and A. Smiley, 12-1-12-10. Kingston, N.J.: Civic Research Institute.

(6) Boothby, J. and C. Clements. 2000. A national survey of correctional psychologists. Criminal Justice and Behavior, 27(6):716-732.

(7) Osofsky, H. 1996. Psychiatry behind the walls: Mental health services in jails and prisons. Bulletin of the Menninger Clinic, 60(4):464-480.

Watson, A., P. Hanrahan, D. Luchins and A. Lurigio. 2001. Paths to jail among mentally ill persons: Service needs and service characteristics. Psychiatric Annals, 31(7):421-429.

Wettstein, R. (Ed.). 1998. Treatment of offenders with mental disorders. New York: Guiliford.

(8) Fagan, T. and R. Ax (Eds.). 2003. Correctional mental health handbook. London: Sage.

(9) Deane, F., P. Skogstad and M. Williams. 1999. Impact of attitudes, ethnicity and quality of prior therapy on New Zealand male prisoners' intentions to seek professional psychological help. International Journal for the Advancement of Counselling, 21(1):55-67.

(10) Morgan, R., A. Rozycki and S. Wilson. 2004. Inmate perceptions of mental health services. Professional Psychology: Research and Practice, 35(4):389-396.

(11) Ax, R. and R. Morgan. 2002. Internship training opportunities in correctional psychology: A comparison of settings. Criminal Justice and Behavior, 29(3):332-347.

(12) Steadman, H., E. Holohean Jr. and J. Dvoskin. 1991. Estimating mental health needs and service utilization among prison inmates. Bulletin of the American Academy of Psychiatry and Law, 19(3):297-307.

(13) Teplin, L., K. Abram and G. McClelland. 1997. Mentally disordered women in jail: Who receives services? American Journal of Public Health, 87(4):604-610.

(14) Lovell, D., G. Gagliardi and P. Peterson. 2002. Recidivism and use of services among persons with mental illness after release from prison. Psychiatric Services, 53(10):1290-1296.

(15) See Kupers, T. 2001. Psychotherapy with men in prison. In New handbook of psychotherapy and counseling with men: A comprehensive guide to settings, problems and treatment approaches (Vol. 1 and 2), eds. G. Brooks and G. Good, 170-184. San Francisco: Jossey-Bass.

Rappaport, R. 1982. Group therapy in prison. In Group psychotherapy and counseling with special populations, ed. Martin Seligman, 215-227. Baltimore: University Park.

(16) Deane, F. et. al. 1999.

(17) Williams, M., P. Skogstad and F. Deane. 2001. Attitudes of male prisoners toward seeking professional psychological help. Journal of Offender Rehabilitation, 34(2):49-61.

(18) See Deane, F. et. al. 1999.

Williams, M. et al. 2001.

Jarrod S. Steffan, M.A., is a doctoral candidate, Clinical Psychology Program, Department of Psychology, Texas Tech University in Lubbock. Robert D. Morgan, Ph.D., is co-director, Division of Counseling Psychology, Department of Psychology, Texas Tech University.
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Title Annotation:CT FEATURE
Author:Steffan, Jarrod S.; Morgan, Robert D.
Publication:Corrections Today
Geographic Code:1USA
Date:Feb 1, 2005
Previous Article:Clinical practice in segregation: the crucial role of psychologists.
Next Article:Best practices in corrections: using literature to guide interventions.

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