Dr. Morgan, Dr. Steffan, and Mr. Shaw are affiliated with the Department of Psychology, Texas Tech University, Box 42051, Lubbock, TX 79409-2051 (e-mail: robert.morgan@ttu.edu). Mr. Wilson is with Correct Care Solutions., El Dorado, Kansas.

With exponential growth in the number of inmates presenting with mental illness (1,2,3,4,5,6,7), correctional institutions have become the de facto mental health setting for persons with mental illness (1,5,8,9,10). In fact, there are approximately twice as many incarcerated offenders with mental illness as there are patients in state psychiatric facilities (2,9). An international review involving 22,790 prisoners observed that "the risks of having serious psychiatric disorders are substantially higher in prisoners than in the general population" (2). Not surprisingly, an estimated 20% of inmates need mental health care (11), with recent estimates indicating that approximately 50% of inmates have mental health problems (12).

With continued growth in prison construction, overcrowding, and incarceration of mentally ill offenders and without concomitant increases in staffing (13,14), service options, or mental health screenings (15), a few investigations have been conducted of inmate service utilization, including types of services offered (16) and attitudes toward and willingness to seek mental health services (17,18,19). Nevertheless, little is known about the factors contributing to the alarming discrepancy between inmate mental health needs and service utilization (20).

As many as 45% of inmates with severe psychiatric illnesses do not receive mental health services; however, female inmates and white inmates have been found to be more likely to utilize mental health services than male inmates and ethnically diverse inmates, respectively (20). A recent survey evidenced improvement, showing approximately 79% of prisoners with mental illness received mental health services (21), although, again, female inmates utilized more mental health services than did male inmates.

Mental health service utilization is a concern in jails as well, because most jail inmates do not access available mental health services (22). In fact, 10% of jail inmates or fewer utilized mental health services, a rate lower than that of inmates in prisons. These results are particularly disturbing considering that jail inmates are more likely than prison inmates to commit suicide (23). Similarly, 77% of female inmates in a large Midwestern jail did not receive needed mental health services during their incarceration (24). These findings raise questions regarding barriers to receipt of mental health services among jail inmates.

Barriers to inmates' willingness to seek mental health services have been questioned for years. However, only recently have empirical investigations begun to systematically examine inmates' perceptions and attitudes toward mental health services. Among New Zealand prisoners, those with a positive attitude toward mental health treatment and those with a previously helpful experience were more likely to seek mental health services (17). Furthermore, New Zealand prisoners identifying as persons from an ethnic minority group had more negative attitudes toward seeking mental health treatment. In a follow-up study, inmates in greater psychological distress and those with fewer concerns about mental health stigmas were more likely to utilize mental health services (19).

More recently, research has shown that the type of problems inmates experience did not affect mental health service utilization (18). Security level, however, influenced negative perceptions of services (18). Specifically, newly incarcerated inmates reported greater concern about social perceptions and institutional concerns for participating in mental health treatment, whereas maximum-security inmates endorsed greater concern about how information disclosed in the course of mental health treatment would be used against them.

Another study revealed that inmates were more likely to seek help for a "personal-emotional" problem than for suicidal thoughts (25). The study further found that inmates with suicidal ideation may not seek treatment because of possible seclusion; other barriers to treatment seeking among inmates with suicidal ideation were sequelae to depressed feelings, concern about negative reactions from inmates and staff, concerns regarding issues of trust, and aversive prison suicide management procedures (25).

The purpose of this study was to expand on previous results of a survey study (18). Specifically, this study investigated the underlying factor structure of problems for which inmates may seek services as well as the barriers to seeking services for these problems. This study also investigated whether inmates with prior mental health treatment and those without such prior treatment differed with regard to their willingness to seek services and with regard to reported barriers to service utilization.

Participants

Participants for this study consisted of 418 incarcerated adult males from a Midwestern state department of corrections: 148 (35%) from a maximum-security correctional facility, 147 (35%) from a reception and diagnostic unit, and 123 (29%) from a minimum-security correctional facility. The inmates had a mean±SD age of 32.96±10.08 years and were predominantly Caucasian (196 persons, or 47%) and African American (128 persons, or 31%). However, other racial groups were represented, including Hispanic (28 persons, or 7%), American Indian (23 persons, or 6%), Asian (five persons, or 1%), and "other" (27 persons, or 6%). Participants had a mean of 11.76±2.03 years of education. Inmates were incarcerated for a variety of crimes and were serving a median sentence of 51 months, with a life sentence being the modal sentence. The demographic composition of the sample was similar to that of the overall state inmate population.

Materials

A three-page survey was developed to assess inmates' previous experience of and attitudes toward mental health services. More details regarding survey development and research procedures are available (18). The survey assessed a range of mental health-related issues, including types of previous mental health experiences before and after adulthood (that is, age 18), treatment participation status (that is, voluntary compared with mandated or involuntary), quantity of services received, potential problems for which inmates would most likely seek mental health services, and barriers to their willingness to seek mental health services.

Procedure

Participants in the maximum-security and minimum-security facilities were recruited (via verbal invitation to participate) from their housing units, work areas, or education classes. Participants from the reception and diagnostic unit were recruited via verbal invitation during regular inmate orientation sessions.

Before initiating data collection, institutional review board approval for research with human subjects was received for this study. Furthermore, all inmates were provided a complete description of the study, after which written informed consent was obtained.

Statistical analysis

Separate principal components analyses with an oblimin Kaiser normalization rotation were conducted to condense perceived problems for which inmates would receive services and barriers to service utilization into identifiable components. Identification of the optimal solution was based on the Kaiser criterion of eigenvalues (<1.0), examination of the scree plot, interpretability of the solution, and inspection of the communalities (<.70 being ideal) (26). Principal components analyses were employed to identify components that explain the maximum variance possible from the data in order to guide subsequent analyses (27). Nonetheless, we also wished to understand the barriers and problems. Therefore, factor analyses employing principal axis factoring with an oblimin Kaiser normalization rotation were also computed, which resulted in an identical solution as the principal components analyses for inmates' problems. A factor analysis of barriers resulted in a solution similar to that from the principal components analysis, with the exception of the item "mental health services are for 'crazy' people," which loaded slightly better on the third factor (.312) instead of the second factor (.265).

Multivariate analysis of covariance (MANCOVA), with follow-up analysis of covariance (ANCOVA) procedures, examined whether a history of previous mental health treatment (individual, couples, or family therapy) in the community had a significant impact on the types of problems for which inmates would be willing to seek services or barriers to service utilization. Type of security placement (that is, reception and diagnostic unit, minimum security, or maximum security) was entered as a covariate because of previous findings that established a relationship between type of security placement and inmates' perceptions of prison mental health services (18). Length of time served in prison was entered as a covariate in the follow-up ANCOVA for one potential barrier (procedural counseling issues) because of a significant correlation with the dependent variable (Bonferroni-corrected alpha of <.006). Finally, a series of analysis of variance procedures with follow-up pairwise multiple comparison tests examined differences in problems for which inmates would access services and barriers to accessing services resulting from the type (voluntary or mandated) and location (prison, community, or both) of past treatment.

Presenting problems and barriers to service use

Results of principal components analyses resulted in a five-component solution for the problems for which inmates would seek help, which accounted for 72% of the variance (Table 1). The first component, labeled behavioral dyscontrol, reflects problems with self-management, including impulsive or harmful behaviors, anger, psychiatric symptoms, sexual problems, substance use problems, and lifestyle issues. The second factor, physical health concerns, consists of problems with general physical functioning, persistent physical pain, serious medical illnesses, and change in appetite or eating habits. Third is negative affect, which taps stress and anxiety related to being incarcerated and to personal and family issues, depressed mood, and sleep difficulties. Interpersonal relationships is the fourth component and pertains to losses of personal relationships, problems with children or spouse, and other personal relationship problems. Finally, institutional relations, the fifth component, relates to problems with institutional staff and other inmates.

Next, principal components analyses led to the identification of a four-component solution of barriers to inmates' willingness to seek help, which accounted for 66% of the variance (Table 2). The first component is self-preservation concerns and includes concerns regarding confidentiality and perceptions of weakness or colluding with staff. Procedural concerns, the second component, relates to a lack of knowing how, when, and why to access services and anticipated length of services. The third component is self-reliance, which refers to a reliance on self or close others for help. Finally, professional service provider concerns, the fourth component, relates to questions of staff qualifications and dissatisfaction with previous mental health services.

Impact of treatment history

A MANCOVA procedure revealed no significant difference between inmates with past community treatment and those without such treatment for the presenting problems for which they would seek services while incarcerated. However, follow-up univariate analysis revealed that inmates with past community treatment were significantly more likely than those without such treatment to seek mental health services to manage concerns related to negative affect (F=7.48, df=1 and 168, p<.01) and to deal with issues related to interpersonal relationships (F=5.38, df=1 and 168, p<.05). Conversely, there were no significant univariate differences pertaining to behavioral dyscontrol, physical health concerns, or institutional relations.

A second MANCOVA procedure indicated no significant difference between inmates with past community treatment and those without such treatment in regard to barriers to accessing mental health services. However, univariate analyses indicated a trend whereby inmates with no history of community treatment endorsed greater self-preservation concerns about prison mental health services, compared with those with such a history, although this finding was not significant (p=.08). There were no significant findings for the remaining barriers.

Results of an ANCOVA procedure revealed that inmates who reported past community treatment were more likely than those who did not report such treatment to have voluntarily accessed mental health services while incarcerated (F=4.64, df=1 and 329, p<.05) (length of time served was a covariate). Therefore, a MANCOVA procedure explored differences in presenting problems and barriers to service utilization between inmates with a history of community treatment and who voluntarily accessed prison mental health services (N=77) and those with such a history of treatment who had not voluntarily used services during their incarceration (N=132). Although results indicated that there were no significant differences between the five presenting problems for which inmates might access services, there was a significant difference for barriers to service utilization between these two groups (F=3.01, df=4 and 170, p<.05, Wilks' λ=.93). Follow-up univariate analyses revealed that inmates who had not voluntarily accessed services while incarcerated were significantly more likely than those who had to endorse more characteristics of self-reliance (F=11.19, df=1 and 173, p<.001); they were also more likely to exhibit a trend of more concerns about procedural counseling issues (p=.07) and more self-preservation concerns about mental health services (p=.09), although these findings were not significant. There was no significant difference between the groups for professional counseling issues as a barrier to service utilization.

To examine differences between inmates with a history of voluntary treatment and those with a history of mandated treatment, we examined differences for presenting problems and barriers to service utilization. Results of a MANCOVA procedure revealed no significant differences between voluntary and mandated treatment participants for presenting problems for which they would seek help; however, there were significant differences between these two groups for the self-preservation concerns and self-reliance barriers. Specifically, significant main effects revealed that inmates with a history of mandated services evidenced more self-preservation concerns about prison mental health services (F=5.32, df=1 and 137, p<.05) and more self-reliance in regard to their own mental health needs (F=4.62, df=1 and 137, p<.05). Subsequent analyses showed no additional significant differences in procedural concerns or professional service provider concerns, including no significant interaction of type and location or main effects of type or location.

The five factors detailing the problems for which inmates would seek help—behavioral dyscontrol, physical health concerns, negative affect, interpersonal relationships, and institutional relations—are generally consistent with the presenting problems most commonly treated by correctional psychologists (13). Given this consistency, a framework for mental health administrators to conceptualize staffing needs can be developed. Specifically, mental health departments need professional staff who can meet both rehabilitative needs (that is, criminal tendencies) and general mental health needs (for example, negative affect and relationship problems) of the inmate population.

Although these five factors appear congruent with the mental health services provided (13), many inmates remained reluctant to access available mental health services. Potential barriers to inmate service utilization included self-preservation concerns, procedural concerns, self-reliance, and professional service provider concerns. With growing interest in providing educational information (similar to public service educational campaigns, such as "Just Say No") to reduce barriers (18), as well as increased interest in motivational interviewing for inmates, these factors provide an overarching conceptualization from which clinicians can approach inmates. For example, during new inmate orientation, a standard correctional practice, mental health professionals can target these specific barriers by educating inmates about how and when they should access services (procedural concerns); challenging stereotypical beliefs and educating inmates about issues of confidentiality, including limits to confidentiality (self-preservation concerns); discussing benefits of help seeking for functioning inside as well as outside the prison walls (self-reliance); and educating inmates about the qualifications and specialized skills of professional staff (professional service provider concerns). Specifically, increased focus should be on specialized inmate orientation programs geared toward engaging inmates in the treatment process, such as the Sensitizing Providers to the Effects of Correctional Incarceration on Treatment and Risk Management (SPECTRM) program (28). The report by Rotter and colleagues (28) presents a thorough review of a specialized orientation program designed to educate inmates about the prison culture and benefits of mental health services.

Because mental health services are underutilized by inmates in greatest need (20), it is important to understand and address barriers to service utilization in order to increase their willingness to access services. This is particularly important because various mental health interventions and programs have proven effective with inmates (29,30,31,32). By increasing the number of inmates who receive mental health services, several positive outcomes may be realized. For example, because mental illness increases risk of suicide (33) and because suicide rates are higher in correctional than in community settings (34,35), mental health treatment for those otherwise not served may reduce rates of inmate suicide. Moreover, increasing service utilization by inmates who would typically avoid such services may increase institutional functioning, resulting in safer prison or jail conditions for inmates and staff (11,36,37). Furthermore, reducing mental health concerns may enable more inmates to take advantage of rehabilitation programs (11,36).

Results of this study are also informative for correctional mental health professionals performing evaluations of inmates referred for services. Given increasing need for improved screening of new prisoners (15), inmates' utilization of community-based mental health services should become a standard screening question at intake and for those referred for health services. As noted in this study, inmates without a history of community-based treatment are less likely to self-refer (are more self-reliant), and therefore may be less likely to be forthcoming about their problems. Thus it is recommended that any time an inmate is referred for services, health professionals inquire about previous counseling service utilization.

Additionally, inmates with no history of mental health treatment in either the community or while incarcerated harbored greater self-preservation concerns and self-reliance than inmates with prior treatment experience. Thus clinicians should address these issues (barriers) in the initial stages of therapy in an attempt to increase treatment readiness, which leads to increased engagement in the therapeutic process (38).

Although this study provides greater insight into inmates' perceptions of and barriers to mental health services, some limitations should be noted. First, this study was limited to adult male inmates from one state correctional system; thus generalizability to other incarcerated populations is unknown. Also, this study assessed offenders' perceptions during a time of incarceration; it is unknown how offenders' perceptions of mental health services may differ during times when they are not incarcerated. Future studies need to address these limitations.

Despite these limitations the results of this study provide useful information for mental health professionals attempting to work with offenders. In particular, the results provide an overarching conceptualization for barriers hindering inmates' willingness to seek mental health services, as well as for the types of problems for which they are likely to seek services. Additionally, the results of this study highlight the importance of investigations by mental health professionals of previous mental health experiences for possible insight into inmates' likely response style and attitude toward mental health services.

Results of this study indicated five problem areas for which inmates may request mental health services—behavioral dyscontrol, physical health concerns, negative affect, interpersonal relationships, and institutional relations—and four potential barriers to inmates' willingness to seek mental health services—self-preservation concerns, procedural concerns, self-reliance, and professional service provider concerns. Results further indicated that inmates with a history of mental health treatment in the community were more likely than inmates without such a history to seek help for negative affect or interpersonal relationships while incarcerated.

Additionally, inmates with a history of community treatment who had not voluntarily accessed mental health services while incarcerated endorsed significantly greater self-reliance, self-preservation concerns, and procedural concerns as barriers to service utilization. Finally, inmates with a history of mandated services, regardless of the setting, evidenced more self-preservation concerns about prison mental health services and preferred to rely on their own resources for coping with mental health problems.

This study was supported by a research grant from the Texas Tech University Research Enhancement Fund. The authors thank the Kansas Department of Corrections, specifically, Debbie Bratton and Angie Webber, M.S., for their assistance with data collection.

The authors report no competing interests.