We’re all familiar with the budget cuts that are causing havoc within the Texas legislature at this point. Who isn’t aware that Texas is facing a $27 billion dollar shortfall. As of May 4, 2011, the Senate passed their version of the state budgets. While the Senate version is more generous than the House version of the budget (they plan on spending $12 billion more than the House), every state agency will take a hit. While I’m sure we have all heard about the impending budget cuts that will be affecting the Texas public school systems, what we haven’t heard about is how budget cuts will affect the prison system. For a system that already is short on funds, further budget cuts will be extremely detrimental, especially on already underserved populations such as prisoners with TBI or PTSD. The House version of the budget would result in a 16.5% gap between what TDCJ requested and what is provided by the House budget. The House budget plans on cutting funding for providing services for prisoners with special needs (including those with PTSD and TBI) by 45.1%. Imagine the impact this will have on services!
Join in the discussion on budget cuts to our prisons by checking out these sites for more information related to the proposed budget cuts to Texas state prisons:
Interim Digest
brokenchains.us/tdcj/prison-issues/budget.html
Texas Tribune: Procedural Move Allows GOP to Pass Senate Budget
Texas Tribune: Advocates -- Prison Health Cuts Will Prompt Lawsuits
TCJC: Impact of Cuts Under HB 1
Thursday, May 5, 2011
Time Article: Decriminalizing Mental Illness
This article from 2007 does a great job of re-iterating (well, pre-iterating, I suppose) the problems with the fact that we don't have a functioning mental illness infrastructure in this country. As we've said in this space before, it takes a lot more money to imprison the mentally ill than it does to treat them: "Taxpayers in Miami-Dade County spend $100,000 each day to house the mentally ill in prison; moreover, studies show that people with mental illness stay in jail eight times longer than other inmates, at seven times the cost."
It also includes a short history of policy in the United States that goes into a little bit more detail than "Reagan closed the state hospitals in the 1980s," including the nugget that President Kennedy signed a bill in 1963 to create the first national network of mental health facilities. But then he was assassinated, the Vietnam War distracted us, and the project was never funded.
It also includes a short history of policy in the United States that goes into a little bit more detail than "Reagan closed the state hospitals in the 1980s," including the nugget that President Kennedy signed a bill in 1963 to create the first national network of mental health facilities. But then he was assassinated, the Vietnam War distracted us, and the project was never funded.
Solutions: Transcendental Meditation
Check out this article about transcendental meditation behind bars. It doesn't discuss mental health or PTSD specifically, but there is evidence that Transcendental Meditation can be helpful in treating the symptoms of PTSD, and also evidence that it helps with anxiety in general.
Wednesday, May 4, 2011
Sin or Symptom: Does it Matter?
The Brookings Institute (another centrist think tank) has an article by Stephen J. Morse in their "Future of the Constitution" series that presents an interesting counter-argument to the statement that serves as the inspiration for the title of the blog. If scrolling down is to much trouble, allow me to remind you: “The difference between a crime of evil and a crime of illness is the difference between a sin and a symptom.”
Morse recounts the story of a man, Collera, who has a long history of violence and anti-social behavior. Collera is driving one day, and gets into one of those maddening situations where you're stuck behind a slow vehicle and can't pass. But instead of cursing and shaking his fist and maybe flipping off the guy in front of him, Collera commits vehicular manslaughter.
The article goes on to establish that Collera has a genetic profile that is associated with anti-social conduct when paired with severe abuse. The genes in question affect neuro-transmitter levels in a region in the brain that is associated with behavior regulation. And, it just so happens that Collera is indeed the victim of severe abuse.
Now, to be fair, Morse does state that Collera's evaluation results "make no mention of disease or disorder." But the point seems a minor one. Whether the brain abnormality is the result of genetic predipostion or damaged tissue (as in the case of TBI), the salient point is that the person's biology, their physiology, has an effect on their behavior.
Morse argues that, "Human beings are part of the physical universe and subject to the laws of that universe, but, as far as we know, we are the only creatures on earth capable of acting fully for reasons and self-consciously." He warns that, as our genetic and neurological-imaging knowledge and technology progresses, it may eventually undermine "all ordinary conceptions of responsibility and even the coherence of law itself."
His point is, essentially, that this knowledge undermines the idea of free will. And it does -- or it could. Implicitly, it seems like he's arguing that we shouldn't put too much stock in this technology, or this knowledge, because it goes against everything we've believed about ourselves up to now. I think that's the wrong response, though.
First of all, I disagree with Morse when he says we're capable of acting "fully for reasons and self-conciously." I think we all dearly want to believe that we're "rational human beings," but actually we're mostly "dumb animals," with a veneer of rationality on top. Much of the time, I think we use that rationality to explain our actions to ourselves after the fact, rather than actually acting rationally in the first place. This isn't a criticsm, so much as it's an observation.
Second of all, instead of ignoring the unpleasant fact that physiology has an impact on behavior, it seems to me that we're better served by using this knowledge as much as we can. Instead of waiting until someone has committed a crime and then squirming with the truth that it's actually not surprising given his history and physiology, shouldn't we instead try to figure out who is at high risk ahead of time, and give them tools to deal with their disability? Because, for all that it's invisible, and behavioral, surely a genetic or neurological pre-disposition to violence is as much a disability to be coped with as, say, diabetes. And we don't imprison people for that.
Morse recounts the story of a man, Collera, who has a long history of violence and anti-social behavior. Collera is driving one day, and gets into one of those maddening situations where you're stuck behind a slow vehicle and can't pass. But instead of cursing and shaking his fist and maybe flipping off the guy in front of him, Collera commits vehicular manslaughter.
The article goes on to establish that Collera has a genetic profile that is associated with anti-social conduct when paired with severe abuse. The genes in question affect neuro-transmitter levels in a region in the brain that is associated with behavior regulation. And, it just so happens that Collera is indeed the victim of severe abuse.
Now, to be fair, Morse does state that Collera's evaluation results "make no mention of disease or disorder." But the point seems a minor one. Whether the brain abnormality is the result of genetic predipostion or damaged tissue (as in the case of TBI), the salient point is that the person's biology, their physiology, has an effect on their behavior.
Morse argues that, "Human beings are part of the physical universe and subject to the laws of that universe, but, as far as we know, we are the only creatures on earth capable of acting fully for reasons and self-consciously." He warns that, as our genetic and neurological-imaging knowledge and technology progresses, it may eventually undermine "all ordinary conceptions of responsibility and even the coherence of law itself."
His point is, essentially, that this knowledge undermines the idea of free will. And it does -- or it could. Implicitly, it seems like he's arguing that we shouldn't put too much stock in this technology, or this knowledge, because it goes against everything we've believed about ourselves up to now. I think that's the wrong response, though.
First of all, I disagree with Morse when he says we're capable of acting "fully for reasons and self-conciously." I think we all dearly want to believe that we're "rational human beings," but actually we're mostly "dumb animals," with a veneer of rationality on top. Much of the time, I think we use that rationality to explain our actions to ourselves after the fact, rather than actually acting rationally in the first place. This isn't a criticsm, so much as it's an observation.
Second of all, instead of ignoring the unpleasant fact that physiology has an impact on behavior, it seems to me that we're better served by using this knowledge as much as we can. Instead of waiting until someone has committed a crime and then squirming with the truth that it's actually not surprising given his history and physiology, shouldn't we instead try to figure out who is at high risk ahead of time, and give them tools to deal with their disability? Because, for all that it's invisible, and behavioral, surely a genetic or neurological pre-disposition to violence is as much a disability to be coped with as, say, diabetes. And we don't imprison people for that.
What Happens when Mentally Ill Prisoners Become Mentally Ill Citizens
The Urban Institute is a think thank that was formed in 1968 as an outgrowth of President Johnson's awareness of a "need for independent nonpartisan analysis of the problems facing America's cities and residents." A listing of U.S. Think Tanks by Ideology from Spero News lists the Urban Institute as "centrist," which seems like a fair assessment, based on my admittedly surface-level inspection. If anything, a somewhat left-leaning bias might be evidenced by what they research, though now how. That is to say, they concern themselves with social issues, rather than concentrating on economics or foreign policy.
Anyhow, The Urban Institute published a report in 2008 examining health and re-entry. They looked at Physical Health, Mental Health, and Substance Abuse. They're a national think tank based in Washington, D. C, but they did their data collection in Texas (and Ohio).
Prevalence
- 6% of men and 18% of women had the trifecta -- a physical illness, a mental illness, AND substance abuse.
- Fifteen percent of men and 35% of women reported mental health conditions, based on self-report data. The authors of the study estimate that the actual prevalence is double that.
- About 40% of respondents did not receive any treatment for their mental illness while in prison.
- About 16% of men and 31% of women self-reported PTSD
The Urban Institute's report, though, isn't just about prevalence. It's concerned with the re-entry experiences of folks with mental illness (and physical illness & substance abuse). Here's what they found in that regard:
Effects of Mental Illness on Re-entry
- "Respondents with mental health conditions reported poorer outcomes in most domains." In other words, as much as it sucks when you're trying to re-integrate into society to have a physical illness or a substance abuse issue, it sucks more to have a mental illness. It's worth noting that TBI was not on the list of the Urban Institute's physical illensses.
- Mentally ill people of both genders had more problems finding a place to live after release than those who weren't mentally ill. Interestingly, the timing of this varied by gender -- men were more likely to be homeless 8-10 months post release, and women were more likely to be homeless 2-3 months post-release. For both, at 8-10 months post-release, the homeless rate was about 20%. It's just that for women, this was the same as folks without a mental illness. Which is chilling in its own right.
- Part of the reason for the increased homelessness is less family support for the mentally ill. And part of the reason for that is violence -- the mentally ill folks were more likely to have been the victims of violence, and to have perpetrated violence, than those who weren't mentally ill.
- By three months out of prison, only about 36% of mentally ill men & 26% of mentally ill women had found employment. This was much lower the the rates by non-mentally ill folks.
- And finally, mentally ill men & women were more likely to engage in post-release criminal behavior, which isn't surprising, given that they're having problems finding places to live and jobs to support themselves.
The Urban Institute had a number of policy recommendations, but for the most part, it boils down to case management services, starting well before a prisoner's release date, and including linking them to support services that exist in the community, as well as things like Medicaid and SSI Disability. Sounds like a good idea to me.
Sunday, February 27, 2011
Do You Want These People Walking Your Streets? Yes, You Probably Do
When Elizabeth and I and our colleagues were developing the policy brief on TBI and PTSD last semester, we focused solely on the Texas state prison system. Within the context of the project, that made perfect sense – we were partnering with TCJC, an organization concerned with the criminal justice system in Texas. But when we take a step back and consider the issue from a state-wide policy perspective, it becomes glaringly obvious that there’s another angle to consider: the role of community mental health services.
The Texas Tribune reports that it takes $12 a day to care for someone in a community-based mental health setting. In contrast, it takes $137 to provide care in a prison. 12 x 12 = 144, so you’re just about squaring the cost there. Too bad there isn’t a way to divert mentally ill prisoners to community treatment…
Oh, but wait! There actually is a way, and they’re called "diversion courts," so named because they’re courts that divert low-level offenders with mental illness into community treatment, rather than putting them in jail. A cost-benefit analysis I dug up concludes that courts like these have been shown to provide “considerable fiscal benefit to taxpayers.” Considerable, in this case, being $1.2 million cross-system in the first 6 months after arrest. And that’s just for one county. Imagine the savings that would accrue if this were implemented statewide!
Now, I hear what you’re saying -- Texas doesn’t necessarily like to try things just because hippie states like California think it’s a good idea. Fair enough. But that cost-benefit analysis? It was done on a diversion court in our very own Bexar County. That court has been operating – and saving taxpayer money – since 2002. Surely by now we have enough evidence to expand the program to other counties.
Expanding diversion courts makes fiscal sense. Cross-system savings implies that the state spends less money across the board: instead of criminal justice spending $137, health and human services spends $12. I’m no mathematician, but even I can figure out that that’s a good deal. But I suspect one of the reasons Texas hasn’t implemented this statewide is because it does shift a lot of the costs from criminal justice to health and human services. We’re Texas, and we’re tough on crime – which means that we’d rather spend money on criminal justice than on community mental health. That perspective is demonstrated by the proposed state budget. Now, don’t get me wrong, the state is proposing budget cuts for everybody. Criminal justice is looking at a 12.7% reduction. But health and human services is facing a 24.6% cut, the highest of any category.
The Texas Tribune reports that it takes $12 a day to care for someone in a community-based mental health setting. In contrast, it takes $137 to provide care in a prison. 12 x 12 = 144, so you’re just about squaring the cost there. Too bad there isn’t a way to divert mentally ill prisoners to community treatment…
Oh, but wait! There actually is a way, and they’re called "diversion courts," so named because they’re courts that divert low-level offenders with mental illness into community treatment, rather than putting them in jail. A cost-benefit analysis I dug up concludes that courts like these have been shown to provide “considerable fiscal benefit to taxpayers.” Considerable, in this case, being $1.2 million cross-system in the first 6 months after arrest. And that’s just for one county. Imagine the savings that would accrue if this were implemented statewide!
Now, I hear what you’re saying -- Texas doesn’t necessarily like to try things just because hippie states like California think it’s a good idea. Fair enough. But that cost-benefit analysis? It was done on a diversion court in our very own Bexar County. That court has been operating – and saving taxpayer money – since 2002. Surely by now we have enough evidence to expand the program to other counties.
Expanding diversion courts makes fiscal sense. Cross-system savings implies that the state spends less money across the board: instead of criminal justice spending $137, health and human services spends $12. I’m no mathematician, but even I can figure out that that’s a good deal. But I suspect one of the reasons Texas hasn’t implemented this statewide is because it does shift a lot of the costs from criminal justice to health and human services. We’re Texas, and we’re tough on crime – which means that we’d rather spend money on criminal justice than on community mental health. That perspective is demonstrated by the proposed state budget. Now, don’t get me wrong, the state is proposing budget cuts for everybody. Criminal justice is looking at a 12.7% reduction. But health and human services is facing a 24.6% cut, the highest of any category.
Sunday, February 20, 2011
PTS-What?
As Amy mentioned in our first installment of this blog, we spent a great deal of time last year evaluating PTSD and TBI in relation to the Texas and federal prison systems in order to prepare a policy brief for TCJC (Texas Criminal Justice Coalition). Before we get going, we need to define PTSD and TBI, and take a look at how often they occur in prisons. PTSD, otherwise known as posttraumatic stress disorder, is defined by the American Psychological Association as an anxiety disorder that arises from a traumatic event such as a crime, accident, combat, or natural disaster1.
Symptoms include:
Recall an incident that was traumatic for you – perhaps you were in a car accident or were the victim of a crime. Were you jumpy for a while afterwards? Did you keep thinking about what happened, re-living it in your mind, and were you distracted by it enough that normal life and normal emotions just didn’t seem entirely real? That’s what our mind does when it is traumatized. That reaction isn’t actually a disorder, it’s normal. It becomes a disorder when you get stuck there. That’s what PTSD is.
Traumatic Brain Injury, or TBI, has been defined by the National Institutive of Neurological Disorders and Stroke as a brain injury stemming from sudden trauma that affects cognition, emotion, behavior, and inhibition. A person may develop TBI as a result of domestic violence, child abuse, a vehicular accident, combat, and a multitude of other events that may cause brain injury. TBI is one of those blessedly-straightforward names—a Traumatic Brain Injury is an injury to the brain. A traumatic one.
Now that we know what TBI and PTSD are, why is it important to give special attention to them in prison populations? First of all, because people with either PTSD or TBI tend to be more violent. Thus, they may engage in violent criminal behavior (as a result of difficulties managing their anger and stress) that results in them being sent to prison. Being in prison, however, can itself also result in TBI or PTSD. In addition, prison conditions often exacerbate symptoms of PTSD and TBI.
Picture yourself as a war veteran who experienced heavy combat and as a result developed PTSD, then imagine being in a prison where other inmates are yelling and violence is a daily event. Your ability to employ logic, reason, and problem-solving are hampered by your diagnosis of PTSD. On top of that, any suggestion of loud explosions sends you into a panic attack – a panic attack which a guard mistakes for you being disruptive or noncompliant. Now imagine that not only will you be unlikely to be screened adequately for TBI or PTSD upon entry to the prison system, but also that you will receive minimal (if any) care during your sentence. How might your mental state be negatively impacted by this lack of care?
Consider, also, the rates of mental illness in the general population versus the prison population. These numbers are staggering, and they speak to the chicken-egg dilemma alluded to above: having PTSD or TBI makes it more likely that you’ll be in prison; in turn, being in prison makes it more likely that you’ll develop PTSD or TBI. The table below was developed for the policy paper Amy and I co-wrote with several colleagues at the UT Austin School of Social Work2. This data serves as a wake-up call: up to 88% of Texas prisoners are estimated to have experienced a traumatic brain injury, compared to 2% of the general populace. Houston, we have a problem.
* This statistic is from a report on jails, not prisons.
References
Symptoms include:
- Re-experiencing the event through disturbing memories, dreams, illusions or hallucinations, and/or intense psychological and physiological distress when exposed to events or circumstances that remind someone of the original traumatic event
- Avoidant behaviors when presented with circumstances that remind someone of the event such as avoiding places, being estranged or detached from people and events, or displaying limited emotions such as love toward others
- Displaying increased arousal (recall the flight or fight response you learned about in Psych 101?) which may include problems with sleeping, difficulty concentrating, irritability, or hypervigilance
Recall an incident that was traumatic for you – perhaps you were in a car accident or were the victim of a crime. Were you jumpy for a while afterwards? Did you keep thinking about what happened, re-living it in your mind, and were you distracted by it enough that normal life and normal emotions just didn’t seem entirely real? That’s what our mind does when it is traumatized. That reaction isn’t actually a disorder, it’s normal. It becomes a disorder when you get stuck there. That’s what PTSD is.
Traumatic Brain Injury, or TBI, has been defined by the National Institutive of Neurological Disorders and Stroke as a brain injury stemming from sudden trauma that affects cognition, emotion, behavior, and inhibition. A person may develop TBI as a result of domestic violence, child abuse, a vehicular accident, combat, and a multitude of other events that may cause brain injury. TBI is one of those blessedly-straightforward names—a Traumatic Brain Injury is an injury to the brain. A traumatic one.
Now that we know what TBI and PTSD are, why is it important to give special attention to them in prison populations? First of all, because people with either PTSD or TBI tend to be more violent. Thus, they may engage in violent criminal behavior (as a result of difficulties managing their anger and stress) that results in them being sent to prison. Being in prison, however, can itself also result in TBI or PTSD. In addition, prison conditions often exacerbate symptoms of PTSD and TBI.
Picture yourself as a war veteran who experienced heavy combat and as a result developed PTSD, then imagine being in a prison where other inmates are yelling and violence is a daily event. Your ability to employ logic, reason, and problem-solving are hampered by your diagnosis of PTSD. On top of that, any suggestion of loud explosions sends you into a panic attack – a panic attack which a guard mistakes for you being disruptive or noncompliant. Now imagine that not only will you be unlikely to be screened adequately for TBI or PTSD upon entry to the prison system, but also that you will receive minimal (if any) care during your sentence. How might your mental state be negatively impacted by this lack of care?
Consider, also, the rates of mental illness in the general population versus the prison population. These numbers are staggering, and they speak to the chicken-egg dilemma alluded to above: having PTSD or TBI makes it more likely that you’ll be in prison; in turn, being in prison makes it more likely that you’ll develop PTSD or TBI. The table below was developed for the policy paper Amy and I co-wrote with several colleagues at the UT Austin School of Social Work2. This data serves as a wake-up call: up to 88% of Texas prisoners are estimated to have experienced a traumatic brain injury, compared to 2% of the general populace. Houston, we have a problem.
| U.S. Population | U.S. Prisoners | Texas Prisoners | Female Prisoners (U.S. Population) | |
| Serious Mental Illness (%) | 3% 3 | 10% to 15% 4 | Up to 30% 5 | 12%* 6 |
| PTSD (%) | 3.5% 7 | 21% 8 | Not available | 34% 9 |
| TBI(%) | 2% 10 | 60.25 11 | Up to 88% 12 | 69.98% 13 |
| Trauma(%) | 66%14 | Not available | Not available | 98% 15 |
* This statistic is from a report on jails, not prisons.
References
- Elizabeth Endres, Noelle Garza, Corinna Jay, Amy Jones, K. C. Lawrence, and Jason Lee. “Posttraumatic stress disorder and traumatic brain injury in Texas prisons: seeking best practices in screening and care.” Policy brief prepared for Texas Criminal Justice Coalition. University of Texas; Austin, Texas. (2010).
- Ibid.
- "Health Care in the Texas Prison System: A Looming Fiscal Crisis," University of Texas Medical Branch 1-7.
- Ibid.
- Mike Ward, "Nearly a Third of State, County Jail Inmates Have Mental Health Diseases," The Statesman, 19 Feb 2007.
- Henry J. Steadman and Pamela C. Robbins, "Developing and Validating a Brief Jail Mental Health Screen for Women (Final Report)," (2007).
- National Institute of Mental Health, The Numbers Count: Mental Disorders in America, http://www.nimh.nih.gov/health/publications/the-nu.
- Ashley Goff, Emmeline Rose, & David Purves, "Does PTSD Occur in Sentenced Prison Population? A Systematic Literature Review," Criminal Behavior and Mental Health 17, no. 3 (2007): 152-162.
- Hills and others, Effective Prison
- Eric J. Shiroma and others, "Prevalence of Traumatic Brain Injury in an Offender Population: A Meta-Analysis," Journal of Correctional Health Care 16, no. 2 (2010): 147-159.
- Ibid.
- Wald, Hegelson, and Langlois, Traumatic Brain Injury
- Shiroma, Prevalence
- Michelle F. Dennis and others, "Evaluation of Lifetime Trauma Exposure and Physical Health in Women With Posttraumatic Stress Disorder," 15, no. 5 (2009): 618-627.
- B. Green and others, "Trauma, Exposure, Mental Health Functioning, and Program Needs of Women in Jail." Crime & Delinquency 51, no. 1 (2005): 133-151.
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