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Thursday, April 10, 2014
Hawaii: More Mentally Ill in Jails than in State Hospital
By News Release @ 9:55 PM :: 8435 Views :: Health Care, Justice Reinvestment, Law Enforcement

The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey

From Treatment Advocacy Center April, 2014

It has been known for almost 200 years that confining mentally ill persons in prisons and jails is inhumane and fraught with problems. The fact that we have re-adopted this practice in the United States in recent years is incomprehensible. Prison and jail officials are being asked to assume responsibility for the nation’s most seriously mentally ill individuals, despite the fact that the officials did not sign up to do this job; are not trained to do it; face severe legal restrictions in their ability to provide treatment for such individuals; and yet are held responsible when things go wrong, as they inevitably do under such circumstances. This misguided public policy has no equal in the United States.

Table of Contents

Executive Summary

Prisons and jails have become America’s “new asylums”: The number of individuals with serious mental illness in prisons and jails now exceeds the number in state psychiatric hospitals tenfold. Most of the mentally ill individuals in prisons and jails would have been treated in state psychiatric hospitals in the years before the deinstitutionalization movement led to closing the hospitals, a trend that continues even today.

The treatment of mentally ill individuals in prisons and jails is critical, especially since such individuals are vulnerable and often abused while incarcerated. Untreated, their psychiatric illness often gets worse, and they leave prison or jail sicker than when they entered. Individuals in prison and jails have a right to receive medical care, and this right pertains to serious mental illness just as it pertains to tuberculosis, diabetes, or hypertension. This right to treatment has been affirmed by the US Supreme Court.

"The Treatment of Persons with Mental Illness in Prisons and Jails" is the first national survey of such treatment practices. It focuses on the problem of treating seriously mentally ill inmates who refuse treatment, usually because they lack awareness of their own illness and do not think they are sick. What are the treatment practices for these individuals in prisons and jails in each state? What are the consequences if such individuals are not treated?

To address these questions, an extensive survey of professionals in state and county corrections systems was undertaken. Sheriffs, jail administrators, and others who were interviewed for the survey expressed compassion for inmates with mental illness and frustration with the mental health system that is failing them. There were several other points of consensus among those interviewed:

  • Not only are the numbers of mentally ill in prisons and jails continuing to climb, the severity of inmates’ illnesses is on the rise as well.
  • Many inmates with mental illness need intensive treatment, and officials in the prisons and jails feel compelled to provide the hospital-level care these inmates need.
  • The root cause of the problem is the continuing closure of state psychiatric hospitals and the failure of mental health officials to provide appropriate aftercare for the released patients.

Click here for the summary of findings.


The ultimate solution to this problem is to maintain a functioning public mental health treatment system so mentally ill persons do not end up in prisons and jails. To this end, public officials need to:

  • Reform mental illness treatment laws and practices in the community to eliminate barriers to treatment for individuals too ill to recognize they need care, so they receive helpbefore they are so disordered they commit acts that result in their arrest.
  • Reform jail and prison treatment laws so inmates with mental illness can receive appropriate and necessary treatment just as inmates with medical conditions receive appropriate and necessary medical treatment.
  • Implement and promote jail diversion programs such as mental health courts.
  • Use court-ordered outpatient treatment (assisted outpatient treatment/AOT) to provide the support at-risk individuals need to live safely and successfully in the community.
  • Encourage cost studies to compare the true cost of housing individuals with serious mental illness in prisons and jails to the cost of appropriately treating them in the community.
  • Establish careful intake screening to identify medication needs, suicide danger, and other risks associated with mental illness.
  • Institute mandatory release planning to provide community support and foster recovery.
  • Provide appropriate mental illness treatment for inmates with serious psychiatric illness.

A model law is proposed to authorize city and county jails to administer nonemergency involuntary medication for mentally ill inmates in need of treatment.

Hawaii Background

Hawaii is another small state that operates a combined jail-prison system. The two largest correctional facilities, in Honolulu and Waipahu, both hold more seriously mentally ill individuals – assuming that 20 percent of inmates are so affected – than are held at Hawaii State Hospital. In fact, the situation is actually worse, since – according to the 2012 Directory of the American Correctional Association – 1,900 additional male inmates from Hawaii were being held in prisons in Arizona to relieve the overcrowding in Hawaii (Directory, p. 242).

Having so many mentally ill individuals in the correctional facilities has caused major problems. For example, at the Oahu Community Correctional Center, popularly known as the Honolulu Jail, a 32-year-old inmate with paranoid schizophrenia killed his 76-year-old cellmate in March 2013. Advocates said that because of state budget cuts “more mentally ill people are winding up in Hawaii’s jails” (Hawaii News Now, Mar. 13, 2013).

Such cuts have been severe and have even included abolishing the Assertive Community Treatment (ACT) teams, one of the few effective components of the outpatient treatment system. Such fiscal cuts led to “a 33 percent increase in admissions” to the state hospital from 2011 to 2012 and an increase in readmissions of the same patients (KHON2, Aug. 24, 2012).

Current Laws Governing Treatment in Prisons and Jails

The Hawaii Department of Public Safety (HI DPS) is responsible for all inmates in the state; there are no county jails. HI DPS nonemergency involuntary medication policies apply to pretrial detainees and sentenced inmates in the state’s correctional facilities.

HI DPS policy allows for involuntary administration of medication on a nonemergency basis with a court order. The Office of Attorney General initiates a request for an “Order to Treat” from the Court. A request for an Order must document that:

(1) the inmate has a history of severe and persistent mental illness and, based on the inmate’s treatment history and current behavior, is now in need of treatment to prevent a relapse or deterioration that would predictably result in the person becoming imminently threatening or dangerous to self or others; and

(2) the inmate’s current mental status or the nature of the inmate’s disorder limits or negates the inmate’s ability to make an informed decision to voluntarily seek or comply with recommended evaluation or treatment.

A panel consisting of a nontreating physician, the medical director, the Mental Health Branch administrator, and the warden must review renewal of court orders.


View or print the full version of "The Treatment of Persons with Mental Illness in Prisons and Jails" from pdf

View or print an abridged version of "The Treatment of Persons with Mental Illness in Prisons and Jails" from PDF


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