County Jail or Psychiatric Hospital? Ethical Challenges in Correctional Mental Health Care

Approximately 20% of the roughly 2.5 million individuals incarcerated in the United States have a serious mental illness (SMI). As a result of their illnesses, these individuals are often more likely to commit a crime, end up incarcerated, and languish in correctional settings without appropriate treatment. The objective of the present study was to investigate how correctional facility personnel reconcile the ethical challenges that arise when housing and treating individuals with SMI. Four focus groups and one group interview were conducted with employees (n = 24) including nurses, clinicians, correctional officers, administrators, and sergeants at a county jail in Pennsylvania. Results show that jail employees felt there are too many inmates with SMI in jail who would benefit from more comprehensive treatment elsewhere; however, given limited resources, employees felt they were doing the best they can. These findings can inform mental health management and policy in a correctional setting.


Prisons and jails now operate as de facto mental health care institutions. Approximately 2.5 million individuals are incarcerated in the United States; 20% to 25% of those individuals have a serious mental illness (SMI), and 30% to 60% have substance abuse problems (James & Glaze, 2006). This is arguably a result of the widescale closing of psychiatric hospitals over the past half century—a trend referred to as deinstitutionalization— and a paucity of adequate community mental health care. Deinstitutionalization might be more accurately described as trans-institutionalization, whereby individuals who would have typically found themselves inside psychiatric hospitals are now inside jails or prisons (Sisti, Segal, & Emanuel, 2015). Often individuals with SMI commit minor offenses related to their illness and end up incarcerated, where they languish without appropriate treatment (Harcourt, 2011).

Since the early days of deinstitutionalization, the number of people with SMI in jails or prisons has steadily increased as the number of psychiatric hospital beds has decreased significantly. Between 1980 and 1995, the number of incarcerated individuals in jails and prisons in the United States almost tripled (Bureau of Justice Statistics, 1995; Harcourt, 2005). Between 1955 and 2004, the number of public psychiatric hospital beds available per 100,000 population dropped from 340 to 17 (Torrey, Entsminger, Geller, Standley, & Jaffe, 2008). The Treatment Advocacy Center estimates that 50 beds per 100,000 population are necessary to provide treatment to individuals who need inpatient care (Torrey et al., 2008). The lack of psychiatric hospital beds as a result of deinstitutionalization and the shortage of adequate community treatment facilities left those with SMI at risk for incarceration, homelessness, and suicide. A study of 81 American cities found a direct link between the reduction in the number of public psychiatric hospital beds and increased homelessness (Markowitza, 2006). Homelessness is known to be a critical pathway to incarceration for those with SMI (Lamb & Weinberger, 2001). This has left jails and prisons with the ultimate responsibility of providing mental health care (Lamb & Weinberger, 2005). As a result of this shift for individuals with mental illness from psychiatric hospitals to jails and prisons, members of this research team and others have called for an increase in the number of psychiatric hospitals to care for those with SMI (Sisti et al., 2015).

In addition to clinical and logistical challenges, treating such a large population of individuals with SMI inside correctional institutions creates a range of serious ethical challenges related to care access, confidentiality, informed consent, and the ability to refuse treatment (Trestman, 2014). Despite the pervasiveness of these ethical challenges, there has been little research that examines how jail personnel, including medical staff, security personnel, and administrators, navigate common but serious clinical and ethical challenges. To our knowledge, there exist no studies of correctional workers’ perspectives on the ethical issues related to housing and treating inmates with mental illness. Their perspectives are critically important to understanding the complexity of these issues to develop institutional policy solutions to mitigate these challenges.

– Andrea G. Segal, Rosemary Frasso, Dominic A. Sisti

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