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.

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:

• 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.

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References

1. 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).
2. Ibid.
3. "Health Care in the Texas Prison System: A Looming Fiscal Crisis," University of Texas Medical Branch 1-7.
4. Ibid.
5. Mike Ward, "Nearly a Third of State, County Jail Inmates Have Mental Health Diseases," The Statesman, 19 Feb 2007.
6. Henry J. Steadman and Pamela C. Robbins, "Developing and Validating a Brief Jail Mental Health Screen for Women (Final Report)," (2007).
7. National Institute of Mental Health, The Numbers Count: Mental Disorders in America, http://www.nimh.nih.gov/health/publications/the-nu.
8. 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.
9. Hills and others, Effective Prison
10. 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.
11. Ibid.
12. Wald, Hegelson, and Langlois, Traumatic Brain Injury
13. Shiroma, Prevalence
14. 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.
15. B. Green and others, "Trauma, Exposure, Mental Health Functioning, and Program Needs of Women in Jail." Crime & Delinquency 51, no. 1 (2005): 133-151.

Welcome to Sin or Symptom

“The difference between a crime of evil and a crime of illness is the difference between a sin and a symptom.” Malcolm Gladwell wrote this line for a New Yorker piece called "Damaged."* It seems like a perfect summation of the dilemma that this blog will be exploring: the incidence of Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) amongst prisoners of the Texas state prison system. Last year, my blogging partner & I developed a policy brief on the subject for the Texas Criminal Justice Coalition. What we learned is pretty grim. We feel like people need to know about the current state of affairs regarding prisoners with mental disorders in Texas, especially given that our esteemed state legislature is currently in session.

We’ll be introducing some of the best research a little later. For now, suffice it to say that it’s well-established that folks who have either PTSD or TBI are more likely to act violently. The volume of research on prisoners specifically with PTSD or TBI is thin, but the conclusions are consistent: many, many prisoners have either PTSD or TBI – or both.

If we re-conceptualize many of the crimes committed in Texas as crimes of illness rather than crimes of evil -- and there is considerable evidence for this re-conceptualization – the first question that presents itself is, "should we do anything about it?" We can answer this question from both an ethical standpoint and a self-interested one.

Ethically, the answer is straightforward: if you have a prisoner with a health condition, you are ethically bound to care for them, since you have removed their ability to care for themselves. But given the current dire financial circumstances, is it in the state's best interest to treat these inmates' psychological and neurological disorders? Is the benefit worth the cost? While less obvious, we will argue that the answer is the same: yes, we should. More questions flow: How does the state identify those who are suffering from PTSD and/or TBI? How does it care for them? What about after their release? These are the questions we'll be exploring as the weeks go by, as well as looking at what the conditions currently are, and what policies the state legislature is considering.

*Years later, he wrote another piece on plagiarism, in which he discusses the plagiarism of "Damaged" generally and that sentence specifically. I like to think I always cite appropriately; needless to say, I am especially aware of the need in this case.