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Book Forum: CHANGES IN VALUES AND POLICIES   |    
Prison Madness: The Mental Health Crisis Behind Bars and What We Must Do About It
JUSTIN SIMON, M.D.
Am J Psychiatry 1999;156:1826-1826.
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by Terry A. Kupers, M.D. San Francisco, Jossey-Bass, 1999, 289 pp., $25.00.

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This spellbinding exposition on mental illness in prisons disturbs the peacefulness with which we psychiatrists customarily ignore that dark corner of our concerns. As expert witness and civil rights consultant, Terry Kupers has had access to prisons, prisoners, wardens, and guards. He writes in summary of these experiences, "I am repeatedly horrified by the violence prevailing in prisons and jails [which are now] the largest mental asylums in the United States" (p. xix). The atmosphere is governed by brutality among prisoners, and between prisoners and guards. In the isolation units, he says, "I [was] shocked to see the degree of psychosis—inmates screaming obscenities, cutting themselves, and smearing feces—the likes of which I have never seen anywhere else in 25 years of clinical practice" (p. xix).

Nearly two million individuals are now in U.S. jails and prisons, and efforts to treat the mentally ill there are sorrowfully inadequate. Life in prison is unimaginably harsh. On the male side there are beatings, rape, and even retributive murder. Both perpetrators and victims are candidates for long periods of horrific solitary confinement. Needless to say, the mentally ill fare poorly in this setting, and many decompensate, including a large number who were not identifiably ill when they came in. Kupers sees prisons as breeding grounds for mental illness and training grounds for meanness and crime. There is far less violence among the female prisoners, and they band together in sufferance of the male guards. Intrusions on their privacy and dignity are not always just psychological, and these intrusions often reactivate powerful emotional reactions from an abusive past. Seventy percent of incarcerated women are single mothers, and 85% had sole child custody before their incarceration. As a group they worry about their children, and little is done to facilitate visitation and continuity of contact with the outside. Depression and posttraumatic stress disorder are endemic and virtually untreated.

The extent of mental illness in jails and prisons is unknown because prison officials count only those prisoners who show gross psychotic or suicidal symptoms, but Kupers estimates that 10% to 20% of inmates are gravely ill and that many more suffer substantial but less serious conditions. Many forces have converged to entangle the mentally ill in the criminal justice system. There are 85% fewer mental hospital beds now than there were in 1960. Following deinstitutionalization, community mental health resources were reduced, homelessness became criminalized, welfare was cut, and ever fewer mentally ill offenders were diverted into noncorrectional treatment programs. The most vulnerable of the mentally ill had virtually nowhere to go but down.

The prison population has increased 400% in the last 20 years. Overcrowding is a terrific problem, and few are aware of the staggering costs of the prison system. California now spends more on corrections than on higher education, and in the same recent period that the state built 21 new prisons, it opened one new state college. Although 95% of the prisoners are eventually released, psychiatric treatment, rehabilitation, education, quality visitation, discharge planning, and other socializing interventions are underfunded or undeveloped. These programs are mostly regarded as "coddling" by prison staff, despite good evidence that they facilitate successful postrelease adjustment and reduce recidivism. Because of this cruel paradox, the focus shifts at the end of this book from madness in prisons to the madness of prisons.

Kupers postulates a prison-industrial complex. The fears of a poorly informed public are readily manipulated by tough-on-crime politicians, government agencies that depend on crime for their existence, and business and labor interests that thrive only when the correctional industry is robust. Kupers argues that this coalition guides prison policy, which only metes severe punishment and does nothing to influence prisoners constructively. Recidivism is the pretext with which to justify more and harsher prisons. The author lays out a full array of sensible remedies, but he believes that nothing will change until lawmakers have strong public support to stand against the dangerous and wasteful status quo. The problems are systemic, and Kupers hopes one day to see the prisons rehumanized and the social problems that underlie crime redressed.

The immediate lynchpin in prison madness is public ignorance, and with this eloquent book the author hopes to inform and disturb everyone. When prison madness ends, it will be because of books like this, which deserves to be bought, read, discussed, and loaned.

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