V. Seminal Court Cases
In addition to involvement in the initial and subsequent appearances of mentally ill offenders, the courts have been active in clarifying the rights of mentally ill inmates over the past several decades. Prior to this, the courts operated under the “hands-off ” doctrine, which allowed prisons and jails in the United States to operate in relative obscurity. During this time, before the 1960s, the courts held the belief that correctional administrators were better equipped than the judicial system to govern the operation of prisons and jails. As the civil rights movement advanced, courts began to take a more detailed look at inmate complaints, resulting in court intervention under the auspices of inmates’ constitutional rights.
The courts have had a significant impact on the treatment of mentally ill offenders in prisons and jails as well as on the “right to treatment for people with mental illnesses” (Perez, Liefman, & Estrada, 2003). This right was first recognized in the 1972 case of Wyatt v. Stickney at a district court in Alabama. In this decision, the court concluded that there were many treatment options for individuals with mental illness that did not involve warehousing in large state institutions. The court found specifically that institutionalization of the mentally ill did not guarantee “the constitutional right to receive such individual treatment as will give each individual with mental illness a realistic opportunity to be cured or to improve his or her mental condition” (at 785, Wyatt v. Stickney). This effectively placed the burden of treatment of the mentally ill on community-based behavioral health centers, of which few existed because of the previous focus on institutionalization. Thus, the goal of reintegration of mentally ill persons into the community was introduced.
According to Perez et al. (2003), many states “saw deinstitutionalization as an opportunity to save money rather than an opportunity to improve their mental health services” (p. 63). This lack of planning and disregard for the deinstitutionalized individuals led to a dramatic increase in homelessness and incarceration. Perez et al. also made the following observation: “Ironically, instead of deinstitutionalization, we have witnessed the reinstitutionalization of individuals with mental illnesses from deplorable state psychiatric hospitals to correctional institutions, where conditions are often worse” (p. 63).
Just as the courts first began the deinstitutionalization movement in 1972, they began to become more active in prisoner rights issues. One of the key cases related to health care came out of the U.S. Supreme Court in 1976. Although not specifically geared toward mentally ill inmates, it is still considered a landmark case. This case is Estelle v. Gamble, and it had several implications for jails and prisons in the United States:
- It guaranteed prison (jail) inmates medical treatment.
- It established the “deliberate indifference” standards.
- It deemed a lack of medical treatment “cruel and unusual punishment” (Eighth Amendment).
- It stated that the Fourteenth Amendment made the preceding three items applicable to states.
The court considered three issues when discussing “deliberate indifference”:
- The amenability of the patient’s condition to treatment
- The consequences to the patient if treatment does not occur
- The likelihood of a favorable outcome
Deliberate indifference constitutes the “unnecessary and wanton infliction of pain” proscribed by the Eighth Amendment:
Whether the indifference is manifested by prison doctors in their response to the prisoner’s needs or by prison guards in intentionally denying or delaying access to medical care or intentionally interfering with the treatment once prescribed. Regardless of how evidenced, deliberate indifference to a prisoner’s serious illness or injury states a cause of action. (Estelle v. Gamble, 1976, pp. 104–105)
The courts are not in the business of second-guessing health care providers or treatment prescriptions but instead seek to achieve the following:
To ensure that decisions concerning the nature and timing of medical care are made by medical personnel, using equipment designed for medical use, in locations conducive to medical functions, and for reasons that are purely medical. (Neisser, 1977, pp. 956–957)
The courts have also weighed in on treatment issues within correctional facilities. Ruiz v. Estelle (1980) is the seminal case that established widely accepted standards for an adequate prison mental health system. In the Ruiz case, the court held that the Constitution requires the following:
- A systemic program for screening and evaluating inmates in order to identify those who require mental health treatment
- Treatment that entails more than segregation and close supervision of the inmate patients
- The participation of trained mental health professionals, who must be employed in sufficient numbers to identify and treat in an individualized manner those treatable inmates who have serious mental disorders
- Accurate, complete, and confidential records of the mental health treatment process
- A basic program for the identification, treatment, and supervision of inmates with suicidal tendencies
The court also stated that prescription and administration of behavior-altering medications in dangerous amounts, by dangerous methods, or without appropriate supervision and periodic evaluation is an unacceptable method of treatment.
Even though Ruiz v. Estelle was decided in 1980, it was not until the mid-1990s that prisoner mental health treatment received national attention once again. First, in 1993, the case of Casey v. Lewis was brought by female inmates in the Arizona prison system. The court found that the Arizona prison officials were deliberately indifferent to the serious medical needs of female inmates because they did not provide facilities and mental health care services for females that were comparable to those provided to males. The court found that this was a violation of the Eighth Amendment. In its decision, the court cited the following problems:
- Inadequate screening of incoming inmates. For women, unqualified security staff made the decision as to which women were mentally ill.
- Records of all inmates were not routinely reviewed, and mentally ill inmates did not receive help until they asked for it or their condition deteriorated.
- Inadequate staffing of psychiatrists and psychologists.
- Delays in assessment and treatment.
- Use of lockdown as an alternative to mental health care; the court characterized this as “appalling.”
- Problems with monitoring of, and delays in receipt of, psychotropic medication. Medication was prescribed, continued, and discontinued without face-to-face evaluations by psychiatrists. Also, there was no method to ensure that patients take their medication.
- Insufficient mental health programming.
- Behavior modification implemented by untrained security officers.
Casey v. Lewis brought to light the use of “unqualified security staff ” in screening and the implementation of behavioral modification techniques for mentally ill inmates. As a result, the court determined that mental health screening and mental health treatment should be provided by “qualified mental health personnel,” defined by Blough (2004) as “physicians, psychiatrists, psychologists, physician assistants, nurses, psychiatric social workers, and others who by virtue of their education, credentials and experience are permitted by law to evaluate and care for the mental health needs of prisoners” (p. 5). Following on the heels of Casey v. Lewis, in 1995 Ohio became the center of attention for inmates with mental illness in prisons.
Dunn v. Voinovich (1995) was a comprehensive class action suit that challenged the mental health care practices of the Ohio Department of Rehabilitation and Corrections. According to the decision, the “Dunn Decree” mandated the following:
- That mental health services be provided “within the framework of a community health model” and in the “least restrictive available environment and by the least intrusive measures available” (Dunn v. Voinovich, p. 4).
- Implementation of a three-tiered system of services: (1) inpatient hospital beds for long-term care, (2) residential treatment beds and crisis beds for short-term care, and (3) outpatient care for general population prisoners.
- Hiring a specified number of psychiatrists (25.5 personnel) and other mental health professionals (246.5 personnel).
- Implementation of procedures for housing assignments, disciplinary proceedings, suicide prevention, access to mental health care, restraint procedures, medication delivery systems, proper placement of mentally ill prisoners, improved medical records, screening procedures, staff training, and delineation of rules for transfer of mentally ill prisoners between prisons.
The Dunn Decree formalized the Estelle v. Gamble case and the applicability of deliberate indifference to mental health and mentally ill inmates. In addition, it opened the door for future cases that dealt with proper community linkage of released prisoners with mental health issues. This community linkage philosophy was transformed into what is now known as prisoner reentry. According to the U.S. Department of Justice, Bureau of Justice Statistics (2003), reentry is defined as a broad term used to refer to issues related to the transition of offenders from prison to community supervision. Reentry seeks to equip offenders returning to society with the resources necessary to become productive members of society. This concept was embraced by the Ohio Department of Rehabilitation and Correction under Director Reginald Wilson and signaled a philosophical switch in prisoner treatment and programming for both mentally ill and other inmates. Thus, the Dunn Decree proved to be important in the overall philosophy of corrections in Ohio and throughout the nation.
As was recognized in the Dunn Decree, community linkage plays a vital role in reducing recidivism for all inmates but is particularly important for mentally ill inmates. The landmark case in the area of community linkage is Brad H. v. City of New York (2000). This class action suit, like the Dunn Decree, alleged improper treatment of mentally ill inmates. The major difference in the Brad H. case is that it specifically targeted the failure of New York City and St. Barnabas Hospital to provide discharge planning services to jail inmates receiving psychiatric treatment in city jails.
The case complaint in Brad H. v. City of New York stated that more than 25,000 inmates per year received psychiatric care while in jail, yet few received discharge planning upon release (Barr, 2003). The case revolved around the practice of releasing inmates (whether or not they were mentally ill) by taking them to a subway station and giving them $1.50 and two subway fares while providing no other assistance. The Brad H. case resulted in a comprehensive reform of the New York City jail mental health system’s practices. It effectively provided inmates with discharge planning for continued mental health treatment after release from jail. It also provided assistance with obtaining related services and benefit entitlements. The discharge planning included the following elements: (a) mental health treatment and supportive services (including medication and counseling), (b) public benefits (Medicaid, food stamps, etc.), and (c) transportation to housing or shelter.
Medication was mandated to be provided to mentally ill inmates who were released. The settlement required that inmates in need of psychotropic medication must be given a 7-day supply and a 21-day prescription, as well as an escort or transport to a community clinic or mental health treatment center to ensure continuity of care. Another important mandate made staff accountable for obtaining Medicaid benefits for the inmates who were activated or reactivated upon release from jail. This ensured that the inmate would have access to medication and benefits to promote continuity of care after release.
According to Barr (2003), the Brad H. case ironically sought mental health discharge planning by means of the following:
Attributing to a jail the obligations long-accepted as duties of community mental health treatment providers and hospitals. In finding that New York City had an obligation to provide discharge planning to Brad H. class members, the Court found that the jails were “subject to licensure” by the State Office of Mental Health and, thus, subject to the same legal requirements as other mental health service providers in New York. (p. 68)
This decision meant that jails and prisons would be looked on as mental health service providers instead of correctional facilities that provide mental health treatment. Thus, it opened the door for the argument that the rights guaranteed to hospital patients extend into prison and jail walls.
The aforementioned court cases outlined the rights of mentally ill inmates in prisons and jails. The impact of these decisions was a significant change in the management of mentally ill inmates.