Mental Health First Aid Training in Prisons, Police Departments, and the Presidential Election

By Wendy S. Salkin

It has been widely reported and acknowledged that many incarcerated Americans live with mental illness. In 2014, the Treatment Advocacy Center and the National Sheriffs’ Association published The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey, a joint report that included the following findings:

  • In 2012, there were estimated to be 356,268 inmates with severe mental illness in prisons and jails. There were also approximately 35,000 patients with severe mental illness in state psychiatric hospitals. Thus, the number of mentally ill persons in prisons and jails was 10 times the number remaining in state hospitals.
  • In 44 of the 50 states and the District of Columbia, a prison or jail in that state holds more individuals with serious mental illness than the largest remaining state psychiatric hospital. For example, in Ohio, 10 state prisons and two county jails each hold more mentally ill inmates than does the largest remaining state hospital.

Similarly widely reported and acknowledged is that prisons often either cannot or simply do not serve the mental health treatment needs of those housed within their walls. As Ana Swanson of The Washington Post observed:

Unsurprisingly, many prisons are poorly equipped to properly deal with mental illness. Inmates with mental illnesses are more likely than other to be held in solitary confinement, and many are raped, commit suicide, or hurt themselves.

Solitary confinement is often used as a means of separating inmates living with mental illness from the rest of a prison population. As Jeffrey L. Metzner and Jamie Fellner reported in their March 2010 article, “Solitary Confinement and Mental Illness in U.S. Prisons: A Challenge for Medical Ethics”:

In recent years, prison officials have increasingly turned to solitary confinement as a way to manage difficult or dangerous prisoners. Many of the prisoners subjected to isolation, which can extend for years, have serious mental illness, and the conditions of solitary confinement can exacerbate their symptoms or provoke recurrence. Prison rules for isolated prisoners, however, greatly restrict the nature and quantity of mental health services that they can receive.

Metzner and Fellner further reported that while the experience of isolation associated with solitary confinement “can be psychologically harmful to any prisoner,”

[t]he adverse effects of solitary confinement are especially significant for persons with serious mental illness, commonly defined as a major mental disorder (e.g., schizophrenia, bipolar disorder, major depressive disorder) that is usually characterized by psychotic symptoms and/or significant functional impairments. The stress, lack of meaningful social contact, and unstructured days can exacerbate symptoms of illness or provoke recurrence. Suicides occur disproportionately more often in segregation units than elsewhere in prison. All too frequently, mentally ill prisoners decompensate in isolation, requiring crisis care or psychiatric hospitalization. Many simply will not get better as long as they are isolated.

Fortunately, some prisons are moving away from reliance on solitary confinement and toward alternative methods for providing support for inmates living with mental illness. As CNN reported just last week, prisons in Pennsylvania are training both staff and inmates in Mental Health First Aid.

Mental Health First Aid, developed in Australia in 2001 by Betty Kitchener and Anthony Jorm, is a training program that teaches trainees “how to identify, understand and respond to signs of mental illnesses and substance use disorders.” The aim of the training is to enable trainees to develop “the skills [they] need to reach out and provide initial help and support to someone who may be developing a mental health or substance use problem or experiencing a crisis.”

This development in Pennsylvania’s prisons comes in the wake of a Justice Department investigation into the “use of solitary confinement on prisoners with serious mental illness and intellectual disabilities” by the Pennsylvania Department of Corrections (PDOC), which was opened in May 2013 “after finding a pattern of constitutional violations as well as violations of the Americans with Disabilities Act at the State Correctional Institution in Cresson, Pennsylvania.” On February 24, 2014, the Justice Department notified PDOC that the violations discovered at Cresson were in fact present throughout Pennsylvania’s prison system. Just over two years later, on April 14, 2016, the Justice Department closed its investigation into PDOC’s use of solitary confinement on prisoners with serious mental illness or intellectual disabilities (SMI/ID). In its closing letter to PDOC, the Justice Department stated that “PDOC has demonstrated significant commitment to reforming its use of solitary confinement on prisoners with SMI/ID.” Among the reforms implemented by PDOC that the Justice Department commended in its closing letter was PDOC’s approach the training both its corrections officers and inmates in providing mental health support:

PDOC has trained hundreds of corrections officers and peer specialists to reinforce the efforts of mental health staff and to support prisoners in need of treatment. Today, prisoners interact with officers who are specifically trained in suicide prevention and assessment of risks, mental illness symptoms and management of those symptoms, the impact of solitary confinement on prisoners with SMI/ID, and communication and de-escalation techniques. Also, more than 500 prisoners have reportedly been certified as peer specialists. During our site visits, prisoners told us that these officers and peer specialists have served as valuable resources to them by helping them understand their mental illness and manage their symptoms.

As reported by CNN, the inmates at State Correctional Institution-Benner Township (SCI-Benner), for instance, are trained for 75 hours to become certified peer specialists, a position for which they are paid. The training includes training in Mental Health First Aid.

And, according to Mental Health First Aid (the organization), while Pennsylvania is “one of a few state-wide prison systems to use this program so broadly,” other organizations throughout the United States prison and law enforcement systems are also embracing the program—from deputies in Maryland’s St. Mary’s County Sheriff’s Office to deputies in both Lauderdale and Madison Counties in Alabama and staff members at the Albuquerque Police Department.

The discussion of inmates’ mental health needs is also being advanced in the context of the 2016 United States presidential election. On Monday, August 29, 2016, presidential candidate Hillary Clinton announced a “comprehensive plan to support Americans living with mental health problems and illnesses.” As part of her proposal, Clinton committed to take the following two steps “to improve outcomes for those individuals [living with mental illness] who…end up interfacing with law enforcement”:

  • Dedicate new resources to help train law enforcement officers in responding to encounters involving persons with mental illness, and increase support for law enforcement partnerships with mental health professionals. Even though an increasing number of police encounters or use-of-force incidents involve people with mental health problems, law enforcement officers receive minimal training in how to handle such situations. According to one study, the average police officer receives only 8 hours of training for crisis intervention, which is far below the recommended amount…. Hillary will ensure adequate evidence-based training for law enforcement on crisis intervention and referral to treatment, so that officers can properly and safely respond to individuals with mental illness during their efforts to enforce the law.
  • Prioritize treatment over punishment for low-level, non-violent offenders with mental illnesses. Over half of prison and jail inmates today have a mental health problem, and up to 65% of the correctional population meets the medical criteria for addiction. Many of these individuals are first-time or nonviolent offenders, whose prospects for recovery and reentry would be far enhanced were they to participate in diversionary programs rather than serve time in jail. Hillary will increase investments in local programs such as specialized courts, drug courts, and veterans’ treatment courts, which send people to treatment and rehab instead of the criminal justice system. She will also direct the Attorney General to issue guidance to federal prosecutors, instructing them to prioritize treatment over incarceration for low-level, non-violent offenders. Finally, she will work to strengthen mental health services for incarcerated individuals and ensure continuity of care so that they get the treatment they need.

While it remains to be seen whether these training programs will be adequate to ensure that inmates receive the mental health support they need while incarcerated, one can at least at this point entertain cautious enthusiasm that serious consideration of the mental health needs of inmates is being foregrounded and taken seriously at the federal, state, and municipal levels. And according to James Weitzel, a peer specialist and inmate at SCI-Benner in Pennsylvania, such cautious enthusiasm is warranted:

“A lot of the [corrections officers] here, they really are buying into this”… “Some are being drug in kicking and screaming, but they’re really giving it the effort. When I see someone trying to help somebody, I can appreciate it.”