Mental health treatment falls short of what is expected. Prisoners left without proper treatment and facilities

Authors: Dallandyshe Xhaferri and Melissa Ellin

For decades, Albania sent mentally ill convicts to Zaharia, an institution with a sole focus on providing therapy and treatment. However, the prison — once described as “hell on earth” by the media and Albanian human rights NGOs— closed its doors in November 2021.

Patients of Zaharia were repeatedly beaten and violated by prison guards and were forced to eat food out of bags, relatives of a former inmate said. The facility, they said, was overcrowded, filthy, filled with mold, mice and cockroaches.

“No one cared for their wellbeing,” said the family of “EQ,” who served 10 months in Zaharia for domestic violence and was released prior to its closure. The family has asked that we not use EQ’s real name.

A critical issue for Zaharia was the limited number of medical staff, which family members say was not enough to provide adequate services for the more than 300 patients within the facility. In 2019, two psychiatrists and two doctors worked in Zaharia and the pharmaceutical service was open only one day a week.

Ardita Kolmarku, lawyer/Project manager at The Albanian Helsinki Committee

“Extreme cases of 12 people with mental health problems staying in the same room were also observed in this institution,” said Ardita Kolmarku, lawyer at The Albanian Helsinki Committee, an NGO that investigated Zaharia. “These citizens complained of lack of oxygen.”

The Ministry of Justice said that a lack of government spending contributed to the problems at Zaharia.

When the government closed Zaharia, it transferred 319 prisoners to buildings four and five within Shen Koll Penitentiary Institution on the outskirts of Lezha — renovated at a cost of 97 Million ALL. Families and advocates had hoped the move would improve conditions for prisoners, but this has not been the case.

Shën Koll Prison, new building, same problems

So far, Shen Koll has failed to institute a unique structure for the administration and treatment of mentally ill prisoners, one top government official and advocates said.

Overcrowded and without places where convicts can socialize with each other, this prison does not help improve the mental health of its prisoners.

“They are always nervous and do not engage in any activity, they are violent and the fact that their socialization is not encouraged is a big problem,” said L.M, a police officer at Zaharia’s prison who offered his assessment but requested anonymity.

The Ombudsman said the prison is overcrowded and does not have enough staff to meet the demands of the population, adding that the situation will remain this way until a new plan for how to treat mentally ill prisoners is finalized.

“Working with them [mentally ill prisoners at Shen Koll] is terrible,” L.M. said. “They need doctors, not police.”

The current staff at Shen Koll includes only two psychiatrists, two psychologists and six social workers.

Arjana Rreli, Psychiatrist

“Convicts with mental health problems should be grouped and treated in separate institutions that have at least specialized psychiatric services, so there should be specialized personnel for mental health, they should have the right training and they should work in a team.” said psychiatrist Arjana Rreli, who added that the facility should also have nursing staff specialized in this field as well as therapists to provide maximum assistance.

While Shen Koll’s prison rooms are equipped with toilets and beds for all convicts, overcrowding remains a problem with up to eight people in the same room. Some of those rooms do not provide the required six meters per person of living space. Many of the prison’s problems — including overcrowding — can be attributed to a lack of sufficient funding.

In Croatia during 2019, the government spent around 55 euros per day on inmates, according to the Council of Europe Annual Penal Statistics. In 2014, Greece spent roughly 28 euros on prisoners per day, according to a report from the Quality Employment and Quality Public Services.

The General Directorate of Prisons in Albania says it spends 3189 ALL — about 26 euros — per day for incarcerated individuals. He did not specify if there is a plan for additional spending to provide treatment for mentally ill prisoners.

A Potential Solution

Currently, in Albania, there are 426 prisoners with mental health problems in the prison system and 362 of them have been designated in need of “compulsory treatment.”

“Their mental health makes our work very difficult,” L.M said. “We can’t treat them as other prisoners because they are violent. They take their medicines every day but you can’t talk with them.”

Rreli says for these prisoner-patients to be re-socialized and reintegrated into wider society, the prison needs a staff of specialized doctors for this target group.

“People with mental health problems are a vulnerable contingent, who require different conditions to be treated,” Rreli said.

To provide care for prisoners with mental illness, Rreli said the government needs to designate a facility for treatment. This institution, unlike Zaharia or Shen Koll, would not be a prison. Rather, it would function as a mental institution.

Last November, the Ministry of Justice and the Ministry of Health and Social Protection signed an agreement requiring the establishment of a “Special Medical Institution” dedicated to this task. The Ministry of Health said they are drafting a project proposal for building this Institution in 2023.

The special facility will provide therapeutic care for prisoners with mental health problems, according to international standards, meaning there will be a professional staff of doctors and psychologists along with sanitary conditions.

The U.S. Approach to the Problem

In the United States, federal and state governments are also trying to find the best way to provide mentally ill prisoners with the care they need.

Experts and advocates say the answer is to stop treating convicted criminals with mental illnesses like prisoners.

Elizabeth Matos, Executive Director of Prisoners Legal Services of Massachusetts

“There’s nothing therapeutic about a prison or a jail,” said Elizabeth Matos, executive director of Prisoners Legal Services of Massachusetts. “The idea that you can have real therapy happen in that setting is kind of counterintuitive.”

In 2012, when the country last surveyed its incarcerated population for mental illness, it found that 37 percent of federal and state prisoners and 44 percent of county jail prisoners struggled with mental disorders at some point in their lives, according to the U.S. Department of Justice.

Advocates have asked for changes in the federal prison system since at least 2017 when a nonprofit news outlet called The Marshall Project found that the Federal Justice Bureau (FJB) — which oversees the prisons — offered very few prisoners access to mental health resources. FJB has not commented on the article or made any public announcements about changes to treatment guidelines.

While it is unclear if the number of prisoners with mental health issues has changed, federal prisons, state prisons and county jails each fall into separate jurisdictions, which means treatment plans vary widely.

State by State Efforts

Massachusetts is one of two states in the U.S. that does not have a facility run by the Department of Mental Health to treat individuals awaiting or unfit for trial due to serious mental health issues.

Most states, said Danna Mauch, president and CEO of the Massachusetts Association for Mental Health, divert convicted criminals from prison settings to mental institutions where they are treated like patients, not prisoners, but serious problems still persist.

Brian Sims, senior medical advisor for the National Association of State Mental Health Program Directors

Brian Sims, senior medical advisor for the National Association of State Mental Health Program Directors, said forensic psychiatrists, doctors who deal with prisoner patients, “are struggling every day” to find the best treatment plans for prisoners.

“They’re all saying harmoniously, the jail is just not the place for them,” Sims said.

Instead, Sims said leaders in the field of forensic psychiatry are advocating for diversion programs that will keep individuals with mental disorders out of prisons in the first place.

Sims and Mauch say Michigan offers a good example of forensic psychiatry in action. The state sends pretrial criminals who are deemed unfit for trial, as well as those found not guilty for reasons of insanity, to a mental health facility called the Center for Forensic Psychiatry, not a prison.

Debra Pinals, the Michigan Department of Health and Human Services medical director for Behavioral Health and Forensic Programs, said the center provides a centralized unit to evaluate the care patients receive.

“It allows there to be a focused approach to the issues of people with mental illness in the criminal system,” Pinals said.

But in Massachusetts, for example, mentally ill prisoners are not as lucky. They are often sent to Bridgewater State Hospital (BSH), said Pinals, who previously worked in the state. BSH is run by the Department of Correction, which means it acts like a prison rather than a psychiatric care institution.

Matos said prisons like BSH perpetuate unhealthy stereotypes about those inside them.

“We have a lot of people who are incarcerated, apparently suffering from untreated mental health issues,” Matos said. “What that eventually boils down to is the criminalization of people with mental health issues.”

How to Change

Massachusetts legislators and advocates are currently trying to institute policies that will improve the state’s treatment of prisoners, such as giving control of BSH to the state Mental Health Department. However, Rep. Ruth Balser, who for years has unsuccessfully advocated for legislation to do just that, said change is a group effort.

“It’s really incumbent on our society to build a more robust system of mental health care so that people don’t land in the criminal justice system,” Balser said.

There is no universal solution, Sims said, but diversion is a good place to start.

“If you’re keeping [prisoners] there for as long as some of them do languish in the jails, you’re talking about a lot of taxpayer dollars that could otherwise be compressed into a treatment strategy,” Sims said.

Attorney Andrew Lelling, who led a two-year investigation into the Massachusetts state prisons and found they were violating prisoner rights, said the best way to make change is to provide more funding for the state’s corrections department. This way, it can acquire more staff and overall resources. But that doesn’t guarantee better treatment for the mentally ill.

“Jails and prisons are under-resourced,” Lelling said, “so when they have resources, be it money or personnel, the priority is not going to be mental health treatment.”

However, Massachusetts has earmarked spending for that purpose. It added a line item to its budget in 2019 called “Behavioral Health and Residential Treatment” to better track the department’s spending in certain categories, including resources for prisoners with mental illnesses. In 2019, the state spent around $1 million, and in the past two years that number has increased by around 500 percent to around $5 million, the state budget shows.

But it still isn’t enough, Sims said, and most states are “screaming” to their respective governors and legislatures for help.

“They know they don’t have the funds,” Sims said.

Sims, of the National Association of State Mental Health Program Directors, said the treatment of prisoners with mental illness needs to be a top priority before any meaningful change can happen.

“Some states have it at the top of their agenda, and it is all they talk about,” Sims said. “There’s other states where it just isn’t on their agenda. It’s just what they want to look at right now.”

In Albania, the treatment of mentally ill prisoners doesn’t appear to be a top priority at the moment.  It’s not a topic often discussed by government leaders and only occasionally makes its way into news coverage.  If or when that will change, remains an open question.