Law & Psychiatry: Lost in the Crowd: Prison Mental Health Care, Overcrowding, and the Courts

Prison populations in the United States have skyrocketed in recent decades, increasing by more than 600% in the last 40 years. Approximately 1% of the adult population of the country is incarcerated at any point. On an international scale, the U.S. imprisons a larger percentage of its citizens than any other country, accounting for fully one-quarter of the world's prisoners (1). Many of those inmates experience symptoms of mental illness—the most recent studies suggest that roughly 15% of prisoners and up to a quarter of jail detainees suffer from psychotic disorders. (2) Thus the provision of psychiatric treatment to inmates has become a major concern of correctional systems.

California's prison system exemplifies the trends that exist in many jurisdictions nationwide. The state's reliance on lengthy periods of incarceration as a cornerstone of its crime-fighting strategy caused prison populations to grow at a rate exceeding the system's ability to expand. For much of the 1990s and the first decade of this century, the state's prisons were run at roughly 200% of capacity, hitting a high in 2006 of more than 170,000 prisoners housed in facilities built to hold 80,000.

Because of extreme pressure on available cell space, areas intended for other purposes were converted to hold inmates. Gymnasia, for example, became dormitories, as double- and triple-decked bunk beds filled the cavernous spaces, separated by only narrow aisles. The unavailability of cells meant that some prisoners served their entire sentences in reception areas, some of which had three times as many inmates as they were built to hold.

It is not difficult to imagine that such overcrowding would put extreme pressure on mental health services, and that indeed was the case. However, even before the recent surge in California's prison population, the psychiatric needs of inmates were routinely ignored. In 1990, inmates in the state's prisons filed suit in federal court alleging that the state was deliberately indifferent to their mental health care needs—the standard that must be met for a constitutional violation to be found. When the case, now known as Coleman v. Brown, went to trial in 1995, a federal district court judge found “overwhelming evidence of the systematic failure to deliver necessary care to mentally ill inmates” (3). The court appointed a special master to develop and oversee the implementation of a remedial plan. For a time, things appeared to be getting better, but by 2007, the special master—who had issued more than 70 orders aimed at bringing the system into compliance—reported that earlier “achievements have succumbed to the inexorably rising tide of population” and that things were again getting worse.

Challenging overcrowding in court

In 1976, the U.S. Supreme Court held in Estelle v. Gamble that states have a responsibility under the Eighth Amendment to meet prisoners' basic medical needs (4). Attempts to enforce that right in the federal courts are governed in part by the Prison Litigation Reform Act (PLRA) (5). Among other provisions, that statute addresses an extraordinary remedy that can be applied to overcrowded prison systems. When federal district courts find that less drastic interventions—such as negotiated consent decrees or the appointment of special masters—are inadequate to remedy unconstitutional conditions, they can initiate a process by which the state can be ordered to reduce its prison population. Such a move requires appointment of a special three-judge panel at the district court level with authority to hear evidence and determine whether the statute's prerequisites for a population reduction order have been met.

Specifically, the three-judge court must find that overcrowding is the primary cause of the constitutionally deficient conditions; no other relief would be adequate to remedy the situation; any resulting order is “narrowly drawn and extends no further than necessary”; and substantial weight has been given to any adverse impact on public safety. If these requirements have been met, the panel may order a state to implement a process of reducing its prison population. Should the state object to the court's order, the decision is appealable directly to the U.S. Supreme Court.

Despairing of any other way of compelling California to provide adequate psychiatric treatment to its prisoners, in 2007—17 years after the litigation began and more than a decade after the first order was issued—plaintiffs asked the district court judge in Coleman to convene a three-judge panel. At the same time, a similar request was made by the plaintiffs in a parallel case challenging the constitutionality of general health care in the California prisons, now known as Plata v. Brown. Both requests were granted, and the two cases were consolidated and argued before the special court in November 2008.

The three judges reviewed a series of reports by the special master in Coleman and the court-appointed receiver in Brown that documented the continuing inadequacy of psychiatric and general medical treatment in California prisons. Experts who testified at the hearing affirmed that little had changed. Psychotic prisoners were often held in cages the size of telephone booths, where they were forced to stand in their own excretions. Waiting times for mental health care could approach one year, and suicide rates were significantly higher than those found at comparable facilities in other states. Between one-quarter and one-third of positions for mental health staff were unfilled, and the vacancy rates for psychiatrists sometimes exceeded 50%.

Moreover, overcrowding appeared to play a crucial role in the ongoing failure of the prisons to maintain acceptable standards. Because of the shortage of space in the prisons' reception centers, mental health screening took place in offices shared by several clinicians, affording no privacy to the prisoners being evaluated. Treatment space in the prisons was grossly inadequate to meet the needs of the large numbers of inmates, and shortages of beds in mental health units meant that many prisoners acutely in need of care were placed in inappropriate holding cells. Retention of staff was made more difficult by the abysmal conditions they faced, but even if all available positions had been filled, the number of caregivers would have been inadequate to meet the demand. There were insufficient personnel to distribute prescribed medications or to escort prisoners to and from appointments.

Reviewing the evidence, the three-judge panel concluded that overcrowding was the primary cause of the failure to provide adequate treatment and that unless prison populations were reduced, no other remedies were likely to be effective. Nor was California positioned, in the judges' view, to build its way out of the dilemma, given the state's budget problems. Expert testimony was presented about the degree of census reduction that would be required to achieve conditions allowing provision of reasonable psychiatric and general medical care. On the basis of this evidence, the court ordered California to reduce its prison census to no more than 137.5% of capacity within two years (6).

The judges noted that reaching this goal would not necessarily require the release of prisoners, certainly not dangerous ones. They pointed to four mechanisms by which the state could come into compliance with its order without having a negative impact on public safety: increasing early release of prisoners by expanding “good time” credits, diverting technical parole violators to community-based sanctions or local jails, using similar alternative sanctions for low-risk offenders with short sentences, and expanding rehabilitative programming in both prisons and the community to reduce California's staggering rate of recidivism for released prisoners (roughly 70%).

The court also noted that comprehensive sentencing reform would provide a longer-term structural solution but left the choice of methods to achieve the population target in the hands of the state. Concluding their meticulously written, 184-page opinion, the three-judge panel considered the potential negative impact on the communities to which offenders would be diverted or released and found no likely adverse consequences for public safety.

California's appeal to the U.S. Supreme Court

As anticipated, California appealed the judges' order to the U.S. Supreme Court, which agreed to hear the case. At oral arguments in the fall of 2010, the state argued that it should have been given more time to solve the problems. That argument, though, failed to impress Justice Breyer. Noting that the litigation had begun in 1990, he asked, “So how much longer do we have to wait? Another 20 years?” When the attorney for the state noted that new prisons were being built, Justice Breyer countered that only a quarter of the money necessary had been appropriated and later forced the attorney to admit that expenditure of most of that money still awaited approval.

Justice Alito, on the other hand, concerned about the fit between the remedy proposed and the problem identified, asked whether a more narrowly tailored solution might involve construction of additional prison medical and mental health facilities rather than reduction of the population as a whole.

In the end, the Court's opinion broke down along the usual lines, as the four liberal justices sided with the plaintiffs and the four conservatives supported the state. Justice Kennedy, who cast the swing vote with the liberal bloc, wrote the opinion. Unequivocally endorsing the lower court ruling, he held that all of the prerequisites for a population reduction order under the PLRA had been met and that the three-judge court's decision was fully justified.

Indeed, so troubled was Justice Kennedy by the testimony about the conditions in California's prisons that he appended several pictures to his opinion, including a photograph of the cages in which mentally ill prisoners were forced to stand as they awaited treatment beds. However, in a somewhat unusual move, he also noted that California had the right to return to the three-judge panel to request an extension of the time in which they were required to comply with the order and seemed to invite the state to do so (7).

Dissenting opinions written by Justices Scalia and Alito were joined, respectively, by Justice Thomas and Chief Justice Roberts. In his typically scathing tone, Justice Scalia castigated the Court for upholding what he described as “the most radical injunction issued by a court in our nation's history.” He objected primarily to federal judges assuming oversight of large institutions such as California's prisons, arguing that they were ill suited to be making decisions about everyday prison operations. Justice Alito returned to the point that he had made during the oral arguments, namely that the court's order had not been narrowly drawn because it affected all prisoners and not just those with psychiatric or general medical needs.

How California, which has considerable discretion under the court order, will reduce its prison population is not evident at this point. Governor Brown is reported to prefer transfer of state prisoners to county jails, avoiding any direct releases to the community (8). However, it is unclear whether the state's legislators will appropriate the money for counties to house these additional inmates. In the meantime, California has achieved a reduction of about 10,000 prisoners, largely by paying for them to be housed in correctional facilities in other states. The decision in Plata, however, has implications for the other 49 states as well. They are now on notice that the Supreme Court will take prisoners' rights to appropriate treatment seriously—at least when conditions are as egregious as California's—and will uphold orders to reduce prison populations when they appear to be the only effective remedies. Perhaps that knowledge will have a prophylactic effect in other jurisdictions, preventing their prison systems from reaching the depths so graphically documented in California.