Jails and PrisonsLooking inside total institutionsDefini.docx

Jails and Prisons
Looking inside total institutions
Definition of total institution
Canadian Erving Goffman coined this term
He wrote, “A total institution may be defined as a place of
residence and work where a large number of like-situated
individuals cut off from the wider society for an appreciable
period of time together lead an enclosed formally administered
round of life (Goffman, 1968: 11).
"Total institutions (such as prisons, boarding schools,
psychiatric hospitals, concentration camps, etc. ) are distinctive
and have much in common" (Goffman, 1968: 15) because, as
Goffman points out, they depart from the basic social
arrangements in modern western society "that the individual
tends to sleep, play and work in different places with different
co-participants, under different authorities and without an
overall rational plan" (Goffman, 1968: 17).
Glimpses inside the total institution
It is very difficult to appreciate what life is like in jail or prison
so I have selected a few videos, and stories for you
Please listen to Ismael Nazario who speaks about his experience
in Rikers as a youth
https://www.ted.com/talks/ismael_nazario_what_i_learned_as_a
_kid_in_jail?language=en#t-671125
Also, please read a piece published by the Marshall project here
https://www.themarshallproject.org/2018/07/12/a-day-in-the-
life-of-a-prisoner
Finally, hear the story of Mr. Melendez who spent 17 years on
death row for a crime he did not commit. Now exonerated, he

has visited UTA and spoken about this experience. He paints a
vivid picture of those 17 years here
https://www.youtube.com/watch?v=9k6C7ZVhaHE
Why is working in prisons important for social workers?
Criminal justice system is marked by the confluence of race,
class, gender, and inequality in the United States
Mass incarceration has been called one the most pressing social
problems of our time (Mauer & Chesney-Lind, 2002)
The CJ system is fragmented
Over 50,000 different agencies responsible
Prisons account for the fastest growing segment of government
employment (nearly 750,000 people in 2004)
Most people are imprisoned for non-violent crimes
Remember that Race, Class, Gender Matter
African American men disproportionately imprisoned
Women account for the fastest growing prison population
African American women: 571% increase in 20 years
Latinas: 131% increase in 20 years
Caucasian women: 75% increase in 20 years
More women are incarcerated per capita for drug crimes than
men (about 34% of women and 19% of men)
60% of men and 40% of women unemployed at arrest, 1/3
earned less than 5000$ last year.
Privatization of prisons – total institutions and turning a profit
for shareholders
Beck, A.J. (2000). Prisoners in 1999. Washington, DC: Bureau
of Justice Statistics; Guerino, P., Harrison, P.M., & Sabol, P.M.
(2011). Prisoners in 2010. Washington, DC: Bureau of Justice
Statistics. Prisoners in 1999 available online here:

http://bjs.ojp.usdoj.gov/content/pub/pdf/p99.pdf
Private prisons in Texas
http://www.texasprisonbidness.org/map
https://www.texasobserver.org/private-prison-bubble-bursts/
Draw of Private prisons
Lower costs
Good investment for stakeholders
Cheap labor for big business (IBM, Nortel, Texas Tech, Target,
etc.)
Address massive increase in carceral population
BUT
Safety of inmates and guards compromised
Incentive to increase carceral population
Dodgy ethics
Private facilities
Pay prisoners less for labor (as little as 17 cents per hour or
$20/month)
Less rigid hiring practices
Higher inmate to guard ratios
Not always advantageous to local work force
Running Head: UNTREATED ADHD
1

UNTREATED ADHD
4
Student’s name:
Professor’s name:
Topic:
Institution:
Date:
Untreated ADHD
To solve the problem of untreated ADHD, one solution would
be conducting a risk -benefit analysis. Since many families
struggle with whether to put their ASHD child under treatment
or not, a risk-benefit analysis could greatly help such families
take the bold step in putting their child under ADHD treatment.
In this case, healthcare professionals engaging parents who are
resistant about their child receiving ADHD treatment can,
together with the parent, conduct a risk -benefit analysis to
weigh the pros and cons of the treatment. When defining the
risks, health professionals should focus more on the larger
picture, that is, what the child is set to gain with the ADHD
medication. The advantage of this solution is that since it is the
healthcare professional facilitating the risk-benefit analysis,
they can concentrate more on the positive sides of the ADHD
medication and focus less on the negative effects of the

medication, ultimately winning the support of the parent (Rief,
2015).
Through a risk -benefit analysis, the chances of persuading a
parent to treat their child are high because the healthcare
professional gets to emphasize on the medication benefits and
how these benefits outweigh the risks associated with ADHD
medication. The challenge with this solution is that it might be
hard trying to help parents overcome the fears they have about
placing their child under ADHD medication. Another challenge
is that carrying out a risk -benefit analysis may be a time -
consuming process since it requires responding to every detail
and question posed to the satisfaction of the parent skeptical
about putting their child with ADHD on medication. The second
solution would be creating more awareness as an attempt to set
the record straight (Wright et al., 2015). In this case,
awareness-raising events could be organized to educate
members of the society on the importance of seeking early
treatment for ADHD, and empower those reluctant to seek
treatment to take the initiative. Spreading awareness on ADHD
is also aimed at breaking stereotypes and misconceptions linked
to ADHD treatment, and to facilitate this, evidence-based
information must be used. One advantage with this solution is
that there are many platforms that can be used to raise public
awareness on ADHD, and so chances of reaching a wider
audience, particularly those reluctant to seek treatment, are
high. Creating awareness also makes those unaware of ADHD to
create connections between the problems in life and ADHD,
prompting them to seek medical assistance to find out whether
they indeed have ADHD.
The challenge of creating awareness is that it needs to be done
periodically for it to be more effective. Additionally, with
creating awareness, a lot of effort has to be put to ensure that
the ADHD message reaches the intended audience. In regards to
the risk-benefit analysis, a child or an adolescent’s chances of
being placed under treatment are high, and they will eventually
get experience improved social relationships with friends’

family and schoolmates. In regards to creating awareness, an
adults living with the condition will be empowered to seek
treatment, and this will promote benefits such as increased job
performance, and the ability to sustain work and interpersonal
relationships. Besides the proposed solutions, another idea
would be the wider use of ADHD therapy treatment approaches
to prevent the overreliance of ADHD medication. I would also
propose the implementation of ADHD education programs in
schools to create more awareness of the condition among school
goers.
References
Rief, S. F. (2015). The ADHD book of lists: A practical guide
for helping children and teens with attention deficit disorders.
John Wiley & Sons.
Wright, N., Moldavsky, M., Schneider, J., Chakrabarti, I.,
Coates, J., Daley, D., ... & Sayal, K. (2015). Practitioner
review: pathways to care for ADHD–a systematic review of
barriers and facilitators. Journal of Child Psychology and
Psychiatry, 56(6), 598-617.
PSYC 6393/FPSY 6393/IPSY 6393: Capstone
Social Change
Walden University was founded on the principle of promoting
positive social change. This remains the guiding philosophy as
described in the university’s mission and vision statements:
Mission
Walden University provides a diverse community of career
professionals with the opportunity to transform themselves as
scholar-practitioners so that they can effect positive social
change.
Vision
Walden University envisions a distinctively different 21st-
century learning community where knowledge is judged worthy

to the degree that it can be applied by its graduates to the
immediate solutions of critical societal challenges, thereby
advancing the greater global good.
Social Change at Walden University
Walden University defines positive social change as a deliberate
process of creating and applying ideas, strategies, and actions to
promote the worth, dignity, and development of individuals,
communities, organizations, institutions, cultures, and societies.
Positive social change results in the improvement of human and
social conditions. This definition of positive social change
provides an intellectually comprehensive and socially
constructive foundation for the programs, research, professional
activities, and products created by the Walden academic
community and services offered by Walden’s Center for Social
Change. In addition, Walden University supports positive social
change through the development of principled, knowledgeable,
and ethical scholar-practitioners who are and will become civic
and professional role models by advancing the betterment of
society.
Walden University General Policies and Governance (November
2018)
Writing for Social Change in the Capstone
Developing a social change implications framing.
Remember, these are potential social change implications, so
using language like may, might, could, is appropriate and
preferred.
1. Begin with your sample (individual or group that is the focus
on your Capstone problem). Explain how the results of the
capstone will help the specific individuals or group related to
your study.
2. Consider whether the same is true for the larger population

(community or local municipality). Now that you have
described how the actual individuals might use this information,
think about whether the larger population may see the same
results.
a. How might the larger population benefit?
b. What are the potential outcomes for the larger population if
they took action based on your results?
3. Consider a larger benefit to society (state, national, and
international).
a. If the larger population implements changes, what broader
changes might society benefit from (policy, laws, social views).
b. These are generally larger scale ideas that have broader
implications.
4. Be sure that you tie the potential social change implications
to the problem statement. The goal of the capstone is to address
the problem. As such students should ensure that potential
positive social change implications are related specifically back
to the problem.
Adapted from:
https://academicguides.waldenu.edu/formandstyle/writing/social
change
© Walden University 2019
PSYC 6393/FPSY 6393/IPSY 6393/DPSY 6393: Capstone

Problem
Solution
Preparation
Now that you have critically analyzed the problem, the next step
is generating a solution. Please review the following steps in
creating the problem solution for your identified Capstone
problem.
Step 1
Identify the goal in developing a solution.
Using the evacuation plan problem from the Problem Statement
Examples, the goal would be to prevent the Hurricane Katrina
disaster from occurring again by creating an effective, well-
developed evacuation plan.
Step 2
List several possible solutions that you found support for in the
scholarly literature. Also, include a possible solution that you
created from your own ideas or expertise in this area.
This is a short list of possible solutions for the evacuation plan
for New Orleans:

Have emergency management officials trained on a variety of
evacuation plans from around the country prior to revising the
plan for New Orleans.
Develop ways to educate/inform the entire city about the newly
revised evacuation plan, including how it works and maps
showing where people would go and how they would get there.
Develop evacuation plan drills for the city to practice the plan
to ensure that it works properly.
Step 3
For each possible solution, think about the advantages and
disadvantages. Is it a realistic solution? Is it manageable? What
are the costs and benefits of the solution? What are the
challenges and barriers to the solution?
Here is a sample analysis using the example of evacuation drills
for the city:
This is probably not a realistic plan considering the size of the
city. It would be financially costly, as the emergency staff
would have to be paid and the National Guard troops alerted. It
is probably unmanageable, given that it would require that
residents leave their jobs and schools to participate in a drill.
Step 4

Choose one solution that seems most workable for alleviating
the problem. Describe the advantages and disadvantages of the
solution. What challenges or barriers might occur with this
solution? Discuss the potential for social change that could
occur if this solution is implemented.
Support your problem solution with citations to the research
literature.
© Walden University 2019
Am J Psychiatry 166:1, January 2009 103
Article
ajp.psychiatryonline.org
This article is featured in this month’s AJP Audio, is the subject
of a CME course (p. 123), and is discussed in an editorial by
Dr. Lamb (p. 8).

Psychiatric Disorders and Repeat Incarcerations:
The Revolving Prison Door
Jacques Baillargeon, Ph.D.
Ingrid A. Binswanger, M.D.,
M.P.H.
Joseph V. Penn, M.D.
Brie A. Williams, M.D., M.S.
Owen J. Murray, D.O.
Objective: A number of legal, social, and
political factors over the past 40 years
have led to the current epidemic of psy-
chiatric disorders in the U.S. prison sys-
tem. Although numerous investigations
have reported substantially elevated rates
of psychiatric disorders among prison in-
mates compared with the general popu-
lation, it is unclear whether mental illness
is a risk factor for multiple episodes of in-

carceration. The authors examined this
association in a retrospective cohort study
of the nation’s largest state prison system.
Method: The study population included
79,211 inmates who began serving a sen-
tence between September 1, 2006, and
August 31, 2007. Data on psychiatric dis-
orders, demographic characteristics, and
history of incarceration for the preceding
6-year period were obtained from state-
wide medical information systems and
analyzed.
Results: Inmates with major psychiatric
disorders (major depressive disorder, bi-
polar disorders, schizophrenia, and non-
schizophrenic psychotic disorders) had
substantially increased risks of multiple
incarcerations over the 6-year study pe-
riod. The greatest increase in risk was ob-
served among inmates with bipolar disor-
ders, who were 3.3 times more likely to
have had four or more previous incarcer-

ations compared with inmates who had
no major psychiatric disorder.
Conclusions: Prison inmates with major
psychiatric disorders are more likely than
those without to have had previous incar-
cerations. The authors recommend ex-
panding interventions to reduce recidi-
vism among mentally ill inmates. They
discuss the potential benefits of continu-
ity of care reentry programs to help men-
tally ill inmates connect with community-
based mental health programs at the
time of their release, as well as a greater
role for mental health courts and other
diversion strategies.
(Am J Psychiatry 2009; 166:103–109)
The epidemic of psychiatric disorders in the U.S.
prison system represents a national public health crisis.
Epidemiologic studies show that 15%–24% of U.S. inmates
have a severe mental illness (1–3), and a recent report by
the Bureau of Justice Statistics indicates that half of in-
mates—over 1 million individuals—have at least one

mental health condition (4). Several factors have synergis-
tically led to the excess of mental illness in the U.S. correc-
tional system. In the late 1960s, with the availability of new
antipsychotic medications, a national movement resulted
in the mass closing of public mental health hospitals (5–7).
Many leaders in the psychiatric community argued that
moving patients out of state hospitals and into commu-
nity-based outpatient settings represented a humane al-
ternative to overcrowded and understaffed institutions.
Unfortunately, in most cases, the closing of state hospitals
was not accompanied by the promised number of clinics
and halfway houses necessary to care for released hospital
patients (5–7). In subsequent years, health insurers re-
stricted mental health coverage, private hospitals limited
enrollment of psychotic patients, and civil commitment
laws became more restrictive (5). Additionally, beginning
in the 1980s, the “war on drugs,” which led to an increase
in drug-related arrests and an emphasis on mandatory
and fixed sentencing, resulted in dramatic increases in the
proportion of inmates with psychiatric disorders and sub-
stance abuse problems (8, 9). All of these factors have cul-
minated in a revolving-door phenomenon in which many
mentally ill people move continuously between homeless-
ness and the criminal justice system (5, 10).

Despite the magnitude of this problem, few studies have
examined the association between psychiatric disorders
and recidivism in correctional populations (11–13). Recid-
ivism is generally defined as a relapse into previous crimi-
nal behavior; in most published studies, it is operationally
defined as a repeat arrest or incarceration. These studies,
which have focused on relatively small and specific sub-
groups of the correctional population, have found little or
no association between psychiatric disorders and the risk
of having a single repeat incarceration. To our knowledge,
no study has examined the association of psychiatric dis-
orders with multiple episodes of incarceration. This gap in
104 Am J Psychiatry 166:1, January 2009
PSYCHIATRIC DISORDERS AND REPEAT
INCARCERATIONS
the research is noteworthy given the cyclical nature of in-
carceration and homelessness among many impoverished

mentally ill people in the United States (5, 10). In this
study, we examined whether inmates with one of four
types of major psychiatric disorders had an increased risk
of having multiple episodes of incarceration in the Texas
Department of Criminal Justice (TDCJ) prison system, the
largest state correctional system in the United States (14).
Method
Design and Study Sample
This was a retrospective cohort study of all TDCJ inmates (N=
79,211) who began serving sentences between September 1,
2006,
and August 31, 2007, in any of TDCJ’s 116 facilities throughout
the
state. The inmates’ history of previous TDCJ incarcerations was
determined by examining a comprehensive electronic database
containing all TDCJ incarceration records from September 1,
2000, through August 31, 2006. A previous incarceration was
de-
fined as an incarceration resulting from a distinct criminal of-
fense; previous incarcerations resulting from parole violations
were not included in our analysis. All members of the study co-
hort underwent standard medical and psychiatric examinations

during the intake process. This evaluation lasted approximately
60 minutes and consisted of a detailed medical history, a mental
health screening, a physical examination, and a number of labo-
ratory tests. The study was reviewed and approved by the
Univer-
sity of Texas Medical Branch Institutional Review Board.
Measures
The study was designed to compare the prevalence of having
multiple episodes of incarceration among inmates with any of
four types of major psychiatric disorders: major depressive
disor-
der, bipolar disorders, schizophrenia, and nonschizophrenic psy-
chotic disorders. Nonschizophrenic psychotic disorders included
schizoaffective disorder, delusional disorder, substance-induced
psychosis, and psychotic disorder not otherwise specified. The
mental health screening at the time of the intake evaluation was
conducted in a standardized fashion across all prison sites by
mental health nurses or mental health professionals. The screen-
ing consisted of a standardized diagnostic interview and
included
assessment of the following: display of symptoms of psychiatric
disease; history of mental health treatment; current suicidal ide-
ation; prior suicidal gestures; display of unusual behavior;

affec-
tive distress; and unusual nature of criminal offense. The
purpose
of the intake screening was to determine whether an inmate
should be referred for a formal mental health evaluation. If a re-
ferral was made, the evaluation was conducted by master’s-level
mental health professionals using a DSM-IV-guided interview
structure. A diagnosis of a psychiatric disorder established
during
this evaluation was based on DSM-IV criteria and recorded in
the
inmate’s electronic medical record. All incoming inmates who
had one of the four types of major psychiatric disorders under
study, who reported a history of treatment with psychotropic
medication, or who appeared to require such treatment were
sub-
sequently referred to a staff psychiatrist or a psychiatric
midlevel
practitioner for treatment. Diagnoses that were made or con-
firmed by psychiatric providers were also based on DSM-IV
crite-
ria. Approximately 20% of all inmates were referred for
psychiat-
r i c e v a l u a t i o n d u r i n g th e i r i n c a rc e ra ti o n .
A l l p s y c h i a t r i c

diagnoses used in the analyses in this study were ascertained
dur-
ing the period from September 2006 through August 2007.
All demographic data (age, race/ethnicity, and gender) were
based on inmate self-reports and maintained in a systemwide
electronic medical record that is routinely updated to ensure
that
the information reflects the inmates’ current health status.
Infor-
mation on correctional characteristics (criminal offense classifi-
cation and length of prison sentence) was maintained in a sepa-
rate electronic database. Criminal offense classification was
based on the National Criminal Information Center criminal of-
fense codes associated with the inmates’ current sentence. In-
mates who had at least one violent criminal offense (i.e., homi-
cide, kidnapping, sexual assault, robbery assault, and terrorism)
were classified as violent; inmates who had no such criminal of-
fenses were classified as nonviolent. The two electronic data
sets
were linked using a common numeric identification variable.
Statistical Analyses

All statistical analyses were performed with SAS, version 8
(SAS
Institute, Cary, N.C.). Logistic regression analysis was used to
ex-
amine differences in multiple episodes of incarceration across
the subgroups and to calculate adjusted prevalence odds ratios
and corresponding 95% confidence intervals (CIs). All logistic
re-
gression models were adjusted for age, gender, race/ethnicity,
criminal offense classification, and length of current prison sen-
tence. Information on at least one of the aforementioned demo-
graphic or correctional variables was unavailable in <1% of the
study population; inmates with missing data were excluded from
the analysis.
Results
Of the 71,333 inmates in the study cohort who did not
have any of the four major types of psychiatric disorders,
the vast majority were male (87.2%), were under 50 years
old (90.1%), were currently incarcerated for a nonviolent
offense (79.2%), had no history of a violent offense during
the 2000–2006 period (79.4%), and had a current prison
sentence of less than 2 years (60.1%). The three racial/eth-
nic groups were distributed fairly evenly: 34.3% were non-

Hispanic Caucasian, 30.0% were Hispanic Caucasian, and
35.7% were African American. A total of 7,878 inmates were
diagnosed with major depressive disorder, a bipolar disor-
der, schizophrenia, or a nonschizophrenic psychotic disor-
der. There was substantial variation in several demo-
graphic characteristics according to the psychiatric
disorders under study (Table 1). Among inmates diagnosed
with major depressive disorder and bipolar disorders, fe-
males and non-Hispanic Caucasians were overrepresented
and Hispanics and African Americans were underrepre-
sented. Among inmates with schizophrenia and non-
schizophrenic psychotic disorders, African Americans, in-
mates age 50 or older, and inmates who had violent offense
records (current or previous) were overrepresented.
The percentage of specific criminal offenses was calcu-
lated according to the four major types of psychiatric dis-
orders (Table 2). Assessment of the major violent offenses
showed that, in comparison with inmates who had no psy-
chiatric disorder, those who had any psychiatric disorder,
a bipolar disorder, schizophrenia, or a nonschizophrenic
psychotic disorder had higher rates of assault; inmates
who had schizophrenia or a nonschizophrenic psychotic

BAILLARGEON, BINSWANGER, PENN, ET AL.
disorder had higher rates of homicide; and inmates who
had any psychiatric disorder, schizophrenia, or a non-
schizophrenic psychotic disorder had higher rates of rob-
bery. Assessment of major nonviolent offenses showed
that, in comparison with inmates who had no psychiatric
disorder, those who had any psychiatric disorder, major
depressive disorder, schizophrenia, or a nonschizophrenic
psychotic disorder had lower rates of driving under the in-
fluence; inmates who had schizophrenia or a nonschizo-
phrenic psychotic disorder had higher rates of drug pos-
session; and inmates in all major psychiatric disorder
categories had higher rates of property offenses.
The prevalence of having previous incarcerations was
calculated for inmates with each of the four major types of
psychiatric disorders, using four different threshold val-
ues: ≥1, ≥2, ≥3, and ≥4 incarcerations (Table 3). Odds ra-
tios, adjusted for gender, age, race, current criminal of-

fense classification (violent versus nonviolent), and length
of current sentence, were then calculated to assess the risk
of each threshold value among each of the four groups of
psychiatric disorders. For three of the four categories of
psychiatric disorders (bipolar disorders, schizophrenia,
nonschizophrenic psychotic disorders), the risk of having
multiple incarcerations increased in a stepwise fashion
according to the threshold value (Figure 1). For inmates
with major depressive disorder, the risk of having previous
incarcerations remained relatively stable across all four
threshold values.
Discussion
Our study showed that Texas prison inmates with major
psychiatric disorders were far more likely to have had pre-
vious incarcerations compared with inmates without a
serious mental illness. For three of the categories of psy-
chiatric disorders under study (bipolar disorders, schizo-
phrenia, and nonschizophrenic psychotic disorders), this
risk increased in a stepwise fashion according to the
threshold value for number of incarcerations. The risk of
having four or more incarcerations in the 6-year study pe-
riod was particularly high for inmates with a bipolar disor-

der. In general, these findings suggest a substantially
heightened risk of recidivism among released inmates
with mental illness. As a result of the limited availability of
TABLE 1. Percent Distribution of Demographic and Criminal
Offense Characteristics of the Study Population, by Psychiatric
Disorder
Characteristic
No Psychiatric
Disorder
(N=71,333)
Any Psychiatric
Disorder
(N=7,878)
Major Depressive
Disorder
(N=3,252)

Bipolar
Disorders
(N=2,402)
Schizophrenia
(N=849)
Nonschizophrenic
Psychotic Disorders
(N=1,375)
Male 87.2 71.4 61.3 70.7 91.5 84.1
Race/ethnicity
Non-Hispanic Caucasian 34.3 51.7 53.5 69.2 24.5 33.6
Hispanic Caucasian 30.0 15.6 16.8 12.6 15.6 17.9
African American 35.7 32.7 29.7 18.1 60.0 48.5
Age (years)
16–29 40.5 26.5 25.8 31.1 18.1 25.1
30–49 49.6 62.5 62.0 62.5 62.3 63.6
≥50 9.8 11.0 12.1 6.4 19.6 11.3
Current criminal offense
Violent 19.8 20.6 17.9 19.4 26.6 25.3

Nonviolent 79.2 79.4 82.1 80.6 73.4 74.7
Previous criminal offense
Violent 19.6 22.3 19.4 19.6 29.6 27.9
Nonviolent 79.4 77.7 80.6 80.4 70.4 72.1
Current sentence length
<2 years 74.6 73.6 73.7 74.5 74.5 73.5
≥2 years 25.3 24.6 26.3 25.4 25.5 26.5
TABLE 2. Percent Distribution of Specific Criminal Offenses of
the Study Population, by Psychiatric Disorder
Offense
No Psychiatric
Disorder
(N=71,333)
Any Psychiatric
Disorder
(N=7,878)

Major Depressive
Disorder
(N=3,252)
Bipolar
Disorders
(N=2,402)
Schizophrenia
(N=849)
Nonschizophrenic
Psychotic Disorders
(N=1,375)
Violent offenses
Assault 13.0 16.4a 14.0 16.0a 21.7a 19.7a
Homicide 1.8 2.3 1.9 1.8 3.8 a 3.1a
Robbery 8.6 9.7a 8.2 8.1 12.1a 14.6a
Nonviolent offenses

Driving under the influence 10.8 8.8b 9.3b 10.0 4.8b 8.1b
Drug possession 8.6 8.3 7.2 7.1 12.4a 10.5a
Drug delivery (dealing) 43.3 42.7 42.9 42.1 42.8 42.9
Property offenses 43.2 52.6a 50.5a 54.5a 53.6a 53.7a
a Exhibited a statistically significantly higher percentage of the
criminal offense compared with inmates in the “no psychiatric
disorder” group,
as determined by assessing overlap of 95% confidence intervals.
b Exhibited a statistically significantly lower percentage of the
criminal offense compared with inmates in the “no psychiatric
disorder” group,
as determined by assessing overlap of 95% confidence intervals.
INCARCERATIONS

community-based mental health services, mass downsiz-
ing of state psychiatric institutions, and a legal system
with a limited capacity to discern underlying mental
health problems, many people with serious mental illness
move continuously between crisis hospitalization, home-
lessness, and the criminal justice system (10, 15). To our
knowledge, this is the first study to examine the associa-
tion of psychiatric disorders and multiple episodes of in-
carceration in an entire state prison population.
Only a handful of studies (12, 13, 16, 17) involving cor-
rectional populations have examined the association be-
tween psychiatric disorders and the risk of having a single
reincarceration. In contrast to our findings, each of these
investigations found that inmates with mental disorders
exhibited either comparable (16, 17) or lower (12, 13) rein-
carceration rates for both violent and nonviolent offenses
in comparison with inmates without psychiatric disor-
ders. However, a direct comparison of our results with
those of earlier studies is of limited value because of differ-
ences in sample sizes and methods used to assess psychi-
atric disorders and recidivism. Feder (16) examined rein-
carceration rates among 547 inmates released from the
New York State prison system in 1982 and 1983. Lovell et

al. (17) examined reincarceration rates among 337 men-
tally ill inmates released from Washington State prisons in
1996 and 1997. Teplin et al. (12) assessed violent repeat of-
fenses among 728 male jail detainees in Chicago in 1983
and 1984. Porporino and Motiuk (13) examined all repeat
offenses among 36 Canadian inmates with a major psy-
chotic disorder and 36 comparison inmates with no psy-
chiatric disorder. In each of these studies, findings of com-
parable or lower reincarceration rates among mentally ill
inmates may be due to several factors. For example, in-
mates with psychiatric disorders are reported to stay in
prison longer than others charged with similar crimes
(18). The average time served for U.S. inmates with mental
il lness is 103 months (8.6 years), compared with 88
months (7.3 years) for other prisoners (19). Another possi-
ble factor may be geographic differences in the efficacy of
community-based mental health programs and prison
discharge planning programs in preventing criminal re-
cidivism in former inmates (20).
Our investigation’s novel findings may be attributable to
a number of factors. One possibility is that the criminal
justice policies of Texas result in higher rates of incarcera-
tion among persons with mental illness. Another is that

community-based mental health systems in Texas may
have been less effective in diverting persons with severe
mental illness from the criminal justice system. However,
Texas does have a state-sponsored continuity of care pro-
gram that links inmates with serious mental illness who
are about to be released to treatment resources in their
home communities, including halfway houses and outpa-
tient clinics. The program also provides inmates with a 10-
day supply of their prescribed psychotropic medications.
Unfortunately, few data on inmates’ participation in this
program are currently available.
Several limitations should be considered in interpreting
our study. We examined only incarcerations within the
Texas prison system. If an inmate in our study population
was previously incarcerated in another state, the episode
was not included in our analysis. However, given the large
geographic size of Texas and the limited mobility of our
study population, it is unlikely that a substantial propor-
tion of inmates had been incarcerated in another state’s
prison system. Second, because relatively less severe psy-
chiatric disorders such as anxiety disorders and axis II dis-
orders are not rigorously evaluated in the TDCJ, during ei-
ther the initial mental health screening or subsequent
medical encounters, we restricted our analyses to four

broad categories of severe psychiatric disorders. Addition-
ally, information about a prisoner’s history of substance
abuse is maintained in a separate, confidential TDCJ data-
base that was not available for analysis. Thus, our ability to
assess the extent to which either less severe psychiatric
conditions or substance use disorders contributed, either
independently or comorbidly, to repeat incarcerations
was limited. Third, this investigation was subject to the se-
lection biases associated with most retrospective study
designs. Specifically, inmates who were incarcerated mul-
tiple times may have had a greater probability of being di-
agnosed with a serious mental illness. This bias was prob-
ably mi ni mized by th e s t andard i zed me nt al healt h
evaluation used at intake and by our decision to restrict
our analysis to four categories of the most severe psychiat-
ric disorders.
A fourth limitation of our study was that because of in-
complete access to historical incarceration data, we could
TABLE 3. Risk of Previous Incarcerations Among Inmates, by
Presence of a Psychiatric Disordera
≥1 Incarceration ≥2 Incarcerations ≥3 Incarcerations ≥4
Incarcerations

Disorder %
Odds
Ratio 95% CI %
Odds
Ratio 95% CI %
Odds
Ratio 95% CI %
Odds
Ratio 95% CI
No major psychiatric disorder 38.7 Ref 12.2 Ref 3.6 Ref 1.1 Ref
Any major psychiatric disorder 50.7 1.7 1.6–1.8 20.1 2.0 1.8–
2.4 7.0 2.1 1.9–2.4 2.7 2.4 2.1–2.9
Major depressive disorder 48.5 1.5 1.4–1.6 17.9 1.5 1.4–1.7 5.5
1.5 1.4–1.8 2.0 1.6 1.3–2.1
Bipolar disorders 50.9 1.7 1.6–1.9 20.9 2.1 1.9–2.4 8.0 2.6 2.2–
3.1 3.3 3.3 2.6–4.2
Schizophrenia 51.2 1.4 1.2–1.6 19.7 1.5 1.2–1.8 6.8 1.6 1.2–2.1
2.6 2.0 1.2–3.0
Nonschizophrenic psychotic disorders 54.8 1.8 1.6–2.0 23.9 2.1
1.8–2.4 8.7 2.2 1.8–2.7 3.2 2.4 1.7–3.5

a Odds ratios were adjusted for gender, age, race, current and
previous violent criminal offense classification, current and
previous drug-related
criminal offense classification, and length of current sentence.
not fully examine the extent to which the duration of pre-
vious incarcerations may have contributed to differential
reincarceration rates between inmates with and without
these mental illnesses over the 2000–2006 study period.
Although it is possible that inmates with psychiatric disor-
ders receive shorter sentences and therefore have greater
opportunities to commit new criminal offenses and ulti-
mately to be reincarcerated, this scenario is not supported
by previous studies, which have consistently shown that
mentally ill persons receive longer prison sentences and
have a reduced likelihood of early parole compared with

those who are not mentally ill (13, 19). These results are
consistent with our own findings that TDCJ inmates with
psychiatric disorders had a longer mean current prison
sentence and were more likely than other inmates to be
currently incarcerated for a violent crime. Assuming that
these two variables would serve as reasonable proxies for
previous prison sentence length, we adjusted for both cur-
rent prison sentence length and current criminal offense
classification in all statistical models and found that their
inclusion in the models had only a minimal effect on the
outcome of our analyses. Finally, our findings are highly
dependent on the reliability and validity of the screening
measures, the diagnoses of mental health professionals,
and the accuracy of data entry into the electronic medical
record. Although TDCJ has policies of universal and stan-
dardized medical screening of all inmates at intake, as well
as standardized and validated data entry procedures, it is
possible that some inmates were misclassified or misdiag-
nosed and that some data were entered incorrectly.
Despite these limitations, this is the first study to exam-
ine the association between major psychiatric disorders
and multiple episodes of incarceration within an entire
state prison population. Because this investigation was
carried out in the nation’s largest state prison system,

these findings have a high degree of statistical power and
are likely to be generalizable to other U.S. prison systems.
It is important to recognize, however, that inmates with
mental illness represent a small and distinct segment of
the broader population of mentally ill adults in the United
States and that the overall contribution of mental illness to
criminal activity in our society is small (21).
The results of our study highlight the need to pursue al-
ternatives to incarceration of persons with severe mental
illness. One of the most promising alternatives is the di-
version model, designed to prevent or minimize law en-
forcement detention of the nonviolent mentally ill (22, 23).
Based on a foundation of extensive interagency collabora-
tion between mental health, law enforcement, and crimi-
nal justice systems, the model draws on a wide range of
strategies to divert persons with severe mental illness to
appropriate community-based mental health services in
lieu of incarceration (15, 24).
There are two major types of diversion programs. Pre-
booking programs, which are designed to resolve psychi-
atric emergencies without resorting to arrest, generally are
based on formal liaisons between law enforcement and
mental health personnel (23, 25). An example is the crisis

intervention team, which utilizes specially trained police
officers to redirect individuals with mental illness to treat-
FIGURE 1. Risk of Previous Incarcerations Among Texas
Prison Inmates, by Presence of a Psychiatric Disorder
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5

0
A
d
ju
st
e
d
O
d
d
s
R
a
ti
o
(
9

5
%
C
I)
Any Major Psychiatric
Disorder
Major Depressive
Disorder
Bipolar Disorder Schizophrenia Nonschizophrenic
Psychotic Disorder
Psychiatric Disorders
≥1 Incarceration
≥2 Incarcerations
≥3 Incarcerations
≥4 Incarcerations

INCARCERATIONS
ment instead of the judicial system (22). Preliminary data
suggest that the crisis intervention team program is asso-
ciated with lower arrest rates and criminal justice costs
than other pre- and postdiversion programs (22).
Postbooking programs, as the term implies, attempt to
divert mentally ill offenders to community-based services
after they have been arrested. In contrast to prebooking
programs, the criminal justice system plays a major role in
postbooking diversion (26). One particularly promising
postbooking program is the mental health court, which
was designed to divert nonviolent mentally ill individuals
from jails and prisons into closely supervised treatment
programs (27, 28). The number of mental health courts in
the United States has increased from two in 1997 to ap-
proximately 120 today (27). Unlike traditional courts,
mental health courts have therapeutic goals, such as in-
creasing treatment adherence, and they are presided over

by designated judges (18, 27). Preliminary evidence indi-
cates that participation in a mental health court is associ-
ated with longer periods without criminal recidivism (18).
Another emerging diversion strategy is the forensic asser-
tive community treatment model, which relies on 24-hour
mobile services and comprehensive outreach modalities,
such as mental health and addiction treatment, transpor-
tation, economic assistance, and vocational training (24).
In addition to diversion strategies, the implementation
or expansion of discharge planning or continuity of care
programs for mentally ill inmates who are about to be re-
leased appears warranted. Ideally, such programs should
link released inmates with long-term, community-based
outpatient services to help them manage their mental
health problems and reduce their risk of recidivism. Be-
sides providing outpatient treatment, there is evidence
suggesting that community-based mental health pro-
grams should make efforts to ensure that ex-inmates have
access to acute psychiatric inpatient treatment for an ap-
propriate duration. For example, one study (29) found that
hospitalizations that are too brief may fail to stabilize es-
calating psychiatric symptoms and increase the risk of
criminal recidivism. Other studies have shown that co-
morbid substance use among persons with mental illness

also increases the risk of reincarceration (29, 30), suggest-
ing that the inclusion of drug and alcohol screening and
treatment in community settings may help reduce the rate
of recidivism among mentally ill persons (29).
Finally, a substantial proportion of inmates with mental
illness are incarcerated for violent crimes (20%–25% in our
study), especially felony offenses. Because these individu-
als are generally ineligible for diversion programs, consid-
eration should be given to the development of alternative
correctional facilities that would provide an appropriate
clinical environment, including expanded opportunities
for monitoring and treatment, for inmates suffering from
severe mental illness (31, 32).
A recent study by the Pew Center on the States esti-
mated that, for the first time in U.S. history, more than 1 in
100 adults are confined in an American jail or prison at any
given time (14). This striking statistic does not reflect a
parallel increase in crime; rather, it is a culmination of
criminal justice policies that send more lawbreakers to
prison for longer periods. Although the costs of incarcera-
tion have increased dramatically, little progress has been
made in reducing the rates of recidivism and reincarcera-

tion, particularly among inmates with mental illness (14).
Hence, our finding that inmates with psychiatric disorders
have an increased risk of having multiple incarcerations
has important policy implications. Addressing this public
health crisis adequately will require the continued devel-
opment of novel and integrated interventions, such as
mental health courts, continuity of care programs, and the
development of specialized correctional mental health fa-
cilities. Given the scale and complexity of this problem, it
is likely that a coordinated effort among criminal justice,
mental health, and public health systems will be neces-
sary to reduce the widespread criminalization of the men-
tally ill in America.
Received March 20, 2008; revision received May 30, 2008; ac-
cepted July 14, 2008 (doi: 10.1176/appi.ajp.2008.08030416).
From
the Department of Preventive Medicine and Community Health
and
the Correctional Managed Care Program, University of Texas
Medical
Branch, Galveston; Department of Medicine, University of
Colorado
Denver, Aurora; and the Department of Medicine, University of
Cali-

fornia at San Francisco. Address correspondence and reprint re-
quests to Dr. Baillargeon, Department of Preventive Medicine
and
Community Health, University of Texas Medical Branch, 301
Univer-
sity Blvd., Galveston, TX 77555; [email protected] (e-mail).
All authors report no competing interests.
The authors thank Leonard Pechacek for his editorial assistance.
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Mental Health and Incarcerated People

Overview of the problem
Carceral institutions are largest providers of mental health care
3 times as many SMI in jails and prisons than hospitals
Some estimates state more than 50% of incarcerated individuals
(and 70% of women) qualify for a mental health diagnosis
(Fisher et al, 2014; Gonzalez et al, 2014)
16% of inmates have SMI, about as many have experienced
homelessness prior to arrest (Fisher et al 2014).
30-40% of people with SMI have been incarcerated (Fisher et
al, 2014)
Woefully inadequate care – symptoms worsen with incarceration
MH prisoners 2-3 times more expensive
More likely to be placed in solitary confinement
“In historical perspective, we have returned to the early
nineteenth century, when mentally ill persons filled our jails
and prisons. At that time, a reform movement, sparked by
Dorothea Dix, led to a more humane treatment of mentally ill

persons. For over a hundred years, mentally ill individuals were
treated in hospitals. We have now returned to the conditions of
the 1840s by putting large numbers of mentally ill persons back
into jails and prisons.”
(Torrey et al., 2010)
Kevin DeMott
19 years old held in adult prison
Diagnosed bipolar disorder
4 months solitary confinement for throwing things off balcony,
breaking lightbulbs for self-harm, suicidal behaviors
NAMI: Criminalization of “crisis proportions”
The National Alliance on Mental Illness warned the U.S.
Senate Judiciary Committee in 2016 that criminalization of

people living with mental illness has reached "crisis
proportions“
They called for support of federal, state and local reforms to
overcome failings in both the mental health care and criminal
justice systems.
How does criminalization of SMI people happen?
Deinstitutionalization – when asylums were emptied, the needed
community based services did not appear, and eventually led to
people with serious and persistent mental health problems being
swept off the streets by the police
Contributing factors include:
Homelessness
Substance use
Increased police contact with broken windows policing policies
Revolving door of lack of/absence of treatment – homeless and
using – swept off streets by police – stress of jail – release
….repeat
Deinstitutionalization
Began in the 1960’s. Let’s consider an example from Michigan
1987-2003: 75% of Michigan’s psychiatric facilities closed

1955: 1 psychiatric bed for every 300 Americans
2005: 1 psychiatric bed for every 3000 Americans
Exacerbated by Institutes for Mental diseases (IMD) exclusion
(part of social securities act)
Community care fell far short
Increased homelessness
drug and alcohol use as self-medication (for underlying MI and
stress of streets)
Police contact
Behaviors that frequently accompany mental health problems
lead to charges of trespassing, indecent exposure, resisting
arrest, minor assault, property damage, etc.
Disorderly conduct leads to people being labelled “disordered
accused”
1 in 4 police shootings are people with SMI
But this is not only a police problem, people with mental health
problems often find that CJ involvement exacerbates their
underlying reason for CJ contact – their mental health issues

Effects of Imprisonment
isolation from families and social networks
austere surroundings, loss of privacy and poor physical and
hygienic conditions
aggression, bullying, fear, suspicion and the attitudes of
unsympathetic and uninformed staff
lack of purposeful activity, of personal control, of power to act
and loss of identity;
pressure to escape or to take drugs
shame and stigmatization
uncertainty, particularly among remand prisoners, and concern
about re-integration into the outside world.
Women Inmates and Mental Health
Female inmates had higher rates of mental health problems than
male inmates
73 percent of females versus of 55 percent of males in state
prisons.( Mental Health Problems of Prison and Jail Inmates,
Published September, 2006 Bureau of Justice Statistics, US
Department of Justice. Note: Based on self report data, not
necessarily a formal diagnosis).

Women and Trauma
Sexual Abuse:
57% of females report abuse before admission to state prison
versus 16.1 percent of males.
39 % of female state prison inmates report that they were
sexually abused before admission to state prison versus 5.8
percent of males. (Prior Abuse Reported by Inmates and
Probationers, Published in April, 1999. Bureau of Justice
Statistics, US Department of Justice).
Physical or Sexual Violence:
Nearly 6 in 10 women in state prisons had experienced physical
or sexual abuse in the past.
69 % reported that the assault occurred before age 18.( Women
Offenders, Published December 1999, Bureau of Justice
Statistics, US Department of Justice).
Compare suicide rates
Rates of suicide for local jail inmates and U.S. residents, per
100,000

Suicide is leading cause of death in jails
More than a third — 34 percent — of all inmate deaths at local
jails are self-inflicted, and the rate is increasing (BJS, 2015
report)
7 times higher in jails than prisons (BJS, 2015 report)
face a first-time “shock of confinement”; they are stripped of
their job, housing, and basic sense of normalcy.
Many suicide before they have been convicted at all.
Voice from the field
“One of the most powerful experiences of my professional
career was talking to a young woman-through a crack in the
steel door of her cell-who had been in prison for five years and
isolation for the past eighteen months. She was agitated,
panicky, and scared as she was scheduled to be released the
following week and had nowhere to go. She was someone who
was almost certainly abused as a child; had some degree of
mental illness; had not made a meal or done laundry in years;

had no high school degree; and had been alone for the last year
and a half in a room smaller than my bathroom, and would soon
be released without support or assistance. I couldn't imagine
that she would not end up in some type of prison or mental
health facility. Without extensive support and involvement from
social workers both before and after release, which our current
system does not allow, this young woman is almost certain to
fail.“ (Brown, A., Social Worker and Prison Monitor in IL)
The COVID-19 pandemic has revealed the best and the worst of
us. As we continue to respond to the crisis in the US, there is
increasing media coverage of the impact of the pandemic for
justice-involved people. Please review media sources for
articles that you can directly relate to earlier topics in this class
such as racism, mental health problems, addiction issues,
challenges of reentry, prison conditions, etc. In this post please
summarize the article and link it to class topics. For a great
collection of media articles dedicated to the criminal justice
system, please see The Marshall Project website.

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