Grave Disability in U.S. Jails and Prisons

Laws across the United States authorize involuntary psychiatric care in situations when someone poses a danger to self or others; however, many states also permit involuntary psychiatric care on grounds of grave disability, a legal standard often defined as a person’s inability to provide for basic needs or self-care because of mental illness (1). One example of grave disability might be a person refusing to eat because of delusions about food; another might be someone who repeatedly flees from housing because of auditory hallucinations. Contextual factors, such as the presence of third parties (e.g., family or friends) who can help individuals meet their basic needs, can shape psychiatric and legal determinations of grave disability.

Grave disability during incarceration may seem paradoxical, because correctional facilities must generally provide incarcerated people with basic necessities, such as housing, meals, showers, and clothing. Nonetheless, mental illness is prevalent in U.S. correctional facilities (2), and incarcerated people can still meet criteria for grave disability. This Open Forum examines the assessment and treatment implications of grave disability in correctional contexts, as well as ways to support the well-being of incarcerated people who may meet grave disability criteria.

Assessment of Grave Disability in Correctional Contexts

Grave disability standards can vary among jurisdictions and treatment contexts, influencing whether incarcerated people meet legal criteria for involuntary psychiatric care. Many U.S. states define grave disability by the inability to provide for basic needs because of mental illness, whereas other states incorporate criteria such as the inability to make informed decisions to the point of risk for physical harm or subsume grave disability language under criteria for danger to self (1). These standards for involuntary psychiatric care can also differ among community and correctional contexts. For example, California primarily defines grave disability by a person’s inability to provide for food, clothing, or shelter because of mental illness (1), whereas the California prison system describes grave disability as “a substantial probability, due to a serious mental disorder and incapacity to accept or refuse psychiatric medication, that serious harm to the physical or mental health of the inmate will result” (3).

Assessment of grave disability can be challenging in correctional environments. Having a mental illness does not necessarily mean that someone meets grave disability criteria, and correctional facilities often have shortages of mental health professionals who can help with these determinations (4). Compared with suicidal or violent behaviors, some indicators of grave disability, such as impaired insight into medical needs or decreased nutritional intake, may receive less attention from correctional staff, potentially prolonging the course of untreated mental illness. Further complicating matters, certain disruptive behaviors, such as smearing feces, in correctional facilities can resemble grave disability but may be due to other factors, such as anger, protest, or personality traits.

Despite these challenges, incarcerated people are frequently monitored in correctional facilities, which can uncover signs of impaired self-care (e.g., not bathing or not getting out of bed) that might escape detection in less supervised settings. In certain cases, cellmates, custody staff, and others will recognize when incarcerated people are inadequately caring for themselves and will request assistance from mental health staff. As noted above, some correctional facilities have shortages of mental health staff, and mental health professionals are also in short supply in many communities—most U.S. counties did not have a psychiatrist in 2018 (4, 5). U.S. courts have established that incarcerated people have certain rights to mental health care (4, 6), and incarceration may be the first occasion where someone is seen by a mental health professional who can assist with evaluation regarding grave disability.

Treating Incarcerated People Who Meet Grave Disability Criteria

The main focus of correctional facilities is typically security, rather than psychiatric care, which can influence the treatment of incarcerated people who may meet criteria for grave disability. When someone who is experiencing psychosis floods a cell or throws bodily fluids at staff, custody staff may be trained to respond with punitive measures (e.g., disciplinary charges or restrictive housing), whereas mental health staff might wish to pursue further evaluation and treatment (7, 8). In these circumstances, multidisciplinary collaboration is key to balance the security needs of the correctional environment with the psychiatric needs of incarcerated people (7–9).

Even when referred for involuntary psychiatric care, incarcerated people who meet grave disability criteria are often so ill that they do not understand or accept the need for treatment (1, 2). Some might go along with or not resist psychiatric care; however, others may refuse any treatment, even as their behaviors place them at risk for victimization, including violence, from those around them (2). In certain situations, people who meet grave disability criteria may board up or refuse to leave their cells, leading to cell extractions by custody teams that heighten risks for injury to both the incarcerated person and correctional staff (8).

Incarcerated people deemed to meet grave disability criteria can receive involuntary psychiatric care through various pathways. Involuntary psychiatric hospitalization is one approach, which can entail different legal requirements, such as filing civil commitment petitions or connecting patients with legal assistance, depending on the correctional context and treatment circumstances (2, 10). Some prisons and large jails may have onsite capabilities for inpatient psychiatric care, such as those described in California, Florida, North Carolina, and Utah (11–14). Providing these types of services can generate opposition for several reasons, including perceptions that incarcerated people might be “coddled” or receive better psychiatric care than the general public, as well as concerns about the financial costs for these services (7).

For correctional facilities without these capabilities, involuntary psychiatric hospitalization for patients who meet grave disability criteria typically requires transfer to outside facilities, such as state forensic hospitals or forensic units embedded in community hospitals (2). In 1980, the U.S. Supreme Court ruled in Vitek v. Jones that a prison inmate facing involuntary transfer to a psychiatric hospital is entitled to procedural protections, such as adequate notice of potential transfer and a hearing (10). These procedures may not be required or feasible in all circumstances—for example, during emergency transfer for short-term psychiatric stabilization (6). Whether originating from jails or prisons, involuntary transfers to outside psychiatric hospitals can face additional barriers, including preadmission screening procedures by outside hospitals, psychiatric bed shortages, and stigma against incarcerated people (2). Transfers to outside facilities can also entail considerable financial costs, which may incentivize correctional systems that rely on limited public funds or for-profit contractors for psychiatric services to avoid these transfers whenever possible.

Involuntary psychiatric medication is another approach. When incarcerated people pose an immediate danger to self or others because of mental illness, emergency administration of psychiatric medications may be permissible in some correctional contexts (2, 9). Because grave disability does not always entail immediate harm, nonemergency administration of involuntary psychiatric medications may be necessary. In 1990, the U.S. Supreme Court ruled in Washington v. Harper that prison inmates with mental illness can be involuntarily treated with antipsychotic medications if they are dangerous to self or others, which may include grave disability, and if the treatment is in their medical interest (15, 16); the court also noted that administrative, rather than judicial, hearings can provide sufficient procedural protections (15, 16). Many states have since developed policies, typically based on Washington v. Harper, regarding nonemergency administration of involuntary psychiatric medications in prisons (2). By comparison, jails have faced additional barriers to using this treatment option, including less clear legal guidance and other logistical constraints, often requiring hospitalization to administer psychiatric medications in this manner (2, 9, 17).

Although perhaps rarer, mental health conservatorship, also known as guardianship in some jurisdictions, is an additional treatment pathway. For example, in California, mental health conservatorship is typically reserved for people who remain gravely disabled despite extensive psychiatric care, such as involuntary psychiatric hospitalization (18). In some situations, correctional mental health staff can initiate referrals for conservatorship, and a conservator may be appointed who can authorize psychiatric care for these patients (2, 18).

Paths Forward

There are additional ways by which correctional facilities might prevent incarcerated people with mental illness from becoming gravely disabled and might arrange treatment for those already meeting grave disability criteria. Screening newly incarcerated people for psychiatric symptoms and connecting those who may meet criteria for grave disability with psychiatric care are essential steps. Educating custody staff about indicators of impaired self-care and ways to report warning signs to mental health staff is key. Because incarcerated people at risk for grave disability may struggle with structural aspects of correctional facilities, including long-distance walks to obtain medications or meals and bunk beds with fall risks, these individuals may require mobility devices, housing modifications, or other assistance to support self-care (9).

Most incarcerated people eventually return to the community, and reentry planning, such as scheduling follow-up psychiatric care and supplying psychiatric medications on release, can help support people with mental illness who are undergoing this transition (9). For incarcerated individuals who have been deemed to meet grave disability criteria release from incarceration can lead to additional challenges because of their extensive treatment needs and limited availability of community resources that can meet these needs. For example, continuation of involuntary psychiatric care, including legal authorization for ongoing treatment, placement in long-term care facilities, and coordination of complex medication regimens, can require significant collaboration between correctional and community psychiatric services.

Data on involuntary psychiatric care across the country are often limited (19), and the prevalence, characteristics, and clinical outcomes of incarcerated people deemed to meet grave disability criteria are not well studied. More research is needed regarding the use of grave disability as a legal standard for involuntary psychiatric care among incarcerated people, including potential differences among jails, prisons, and other correctional environments. Developing systems for tracking the use of involuntary psychiatric care in correctional contexts might improve understanding of not only the psychiatric needs of incarcerated people but also the ways in which correctional and community psychiatric services can best meet these needs.