Abstract

To understand the disability and health needs of prisoners, the Vermont Prisoner's Health Coalition sent out a survey to every adult prisoner within the Vermont correctional system in the fall of 2002. Open-ended questions centered on disability, health care, and treatment received by inmates within the Vermont correctional system. 190 surveys were returned, and narrative responses were analyzed using qualitative research methods. Most respondents reported having some kind of disability, including learning, developmental, or psychiatric disabilities. Treatment and accommodations were described as inadequate or non-existent, and long wait times for services were typical. The importance of listening to the voices of prisoners regarding accommodations and supports for their disabilities, and perceptions of the quality of their health care, is emphasized.

Keywords: prisoners with disabilities, Vermont Prisoner's Health Coalition, psychiatric disabilities, learning disabilities, developmental disabilities, medical care for prisoners

Introduction

"Prisons are explicitly about State control..." (Fine & Torre, 2004, p. 16)

Historically, health care in U.S. prisons has been a long-standing concern. In the past, inmates often entered prison in poor health, and once incarcerated, prisons were unable to meet their needs, lacking adequate health care facilities and staff. Additionally, living conditions in prisons caused health problems for prisoners. A national movement to improve and reform prison health care arose to address these concerns (Anno, 2001).

With a total enrollment nationwide of more than two million people, U.S. prisons are increasingly overcrowded and understaffed (Human Rights Watch, 2003). Texas inmates are reported to be sicker than those in the general population (Hunter, 2002). Washington prisons suffer from inadequate health care staff, improper training, and inconsistent standards for care (Galloway, 2003). Hepatitis C, a disabling, chronic condition, infects between 29% and 54% of inmates in California, Connecticut, Maryland, Oregon, Texas, and Virginia (compared to a 2% infection rate in the free population), and is epidemic in California, New Jersey, and Pennsylvania prisons (Wilson, 2003). The rate of infection of inmates for diseases that include Hepatitis C, HIV, tuberculosis, syphilis, Chlamydia, and gonorrhea is as much as 10 times the infection rate for those outside of prison (Abramsky, 2003). All of these issues are heightened for prisoners with disabilities, who, some suggest, form a majority of prison populations (Russell & Stewart, 2001).

Broadly, the number of prisoners with disabilities is substantially higher than it is in the general population (Groom, 1999; Russell & Stewart, 2001). Estimates of the number of youth with disabilities in prison run as high as 70-100% (Leone, Zaremba, Chapin, & Iseli, 1995; Russell & Stewart, 2001). The prevalence of prisoners with intellectual disabilities is much higher than in the general population, both nationally and internationally (Cockram, Jackson, & Underwood, 1998). Some theorize that, as other institutions for people with disabilities have closed their doors or lost funding, they have been replaced by prisons as a place to segregate and surveil people with disabilities (Russell & Stewart, 2001).

In 2001, a loose coalition of professionals and advocates began meeting in Vermont to explore health concerns of Vermont prisoners. Calling themselves the Vermont Prisoner's Health Coalition, they wanted to understand the health needs of prisoners within the Vermont correctional system.

As coalition members began to talk to prisoners, prison advocates, corrections officials, and others, it became quickly evident that one of the most important health issues for Vermont's correctional system was the impact of disability on inmates and prisons. It also became clear that there was little data in Vermont about prison health needs, and the needs of prisoners with disabilities. And there was no information about whether or not Vermont prisoners felt that Vermont's Department of Corrections (DOC) was meeting their disability and health needs. So the Coalition decided to embark on a research project to understand health concerns for Vermont prisoners with disabilities.

This paper, then, addresses the intersection of two different areas, disability and health concerns, in Vermont prisons. I understand disability as being culturally constructed, founded in a social model, and opposed to a medicalized portrayal of difference (Smith, 2004). Disability studies scholars comment, "...disabled people have redefined the problem of disability as the product of a disabling society rather than individual limitations or loss" (Campbell and Oliver, 1996, p. 105). The social model of disability does not see disability as being equated with illness.

At the same time, this paper addresses health concerns, both disability and non-disability related. These health concerns arise from a normative, medicalized construction of health, in some opposition to disability as a social construction. In Western culture, the health needs of people both with and without disabilities are typically addressed by medical social structures founded on modernist, positivist scientific principles. The two constructions of health and disability that I discuss here – one from a social perspective, and one from a normative, medicalized perspective – will seem to be in conflict. They are. The words I use, and the discussion in which I engage, reflect the complexity of these perspectives, ones that I hope do not reflect a simplistic modernist binary.

Some of the health concerns described in the paper do not reflect, in and of themselves, disabilities. These are presented as examples of health concerns experienced by people with disabilities, and that might affect their disability and lives in general. I do not equate disability, as a social construction, and health, as a medical concern.

In this paper, I seek to understand ways in which people with disabilities who are imprisoned experience medical care and support (and its lack) for their disability. I ground my findings in voluntary, first-hand reports of inmates, described in qualitative terms. And I extend previous research on prisoners with disabilities, which relied heavily on either quantitative data generated by state and federal correction systems, or interviews based on professionally designed diagnostic structures. Instead, I hope to provide an unmediated view of prisoner's own conceptions of disability and support.

In many respects, then, I outline here ways in which prisoners with disabilities perceive crime, disability, and punishment. I do not attempt to prove, objectively, that health care and support for people with disabilities in prison are inadequate or inappropriate – that would not reflect the heuristic nature of the data obtained (though I think it is true). While I have noted information from the broad literature addressing whether or not the needs of people with disabilities are adequately addressed in prison, that should not be assumed to be the end of my work. Instead, I outline the personal experiences and concerns regarding health and disability of people with disabilities caught up in the U.S. criminal justice system.

Because this project relies on the words, thoughts, and ideas of prisoners, it is an inherently dangerous text – dangerous in the sense that it speaks against the status quo of prison institutions. Qualitative research in prison settings, and statements by prisoners, are typically delegitimized, "...trivialized by the media, ignored by prison authorities and disqualified by administrative criminologists" (Martel, 2004, p. 58).

I should note, finally, that I speak here as a person with a disability, a normative difference that I keep hidden, mostly, from the culture in which I live, allowing me to pass in a world that values sameness and perfection rather than difference.

Disability in U.S. Prisons

"The State is required to provide adequate medical care to those it confines" (Manville, 2003).

Some estimates of the prevalence of disabilities in prison – especially multiple, co-occurring disabilities – indicate that most inmates have disabilities of one kind or another, many with multiple, co-occurring disabilities. For example, a four-state study of juveniles incarcerated for capital offenses found that nearly 100% had multiple disabilities, described as including "neurological impairment, psychiatric illness, and cognitive deficits", often the result of prolonged physical and sexual abuse (Russell & Stewart, 2001, p. 61). In a survey of 74 women federal inmates in Canada, 77% had serious mental illness, personality disorder, and/or cognitive difficulties (McDonagh, Noel, & Wichmann, 2002). Because prisoners with disabilities form a substantial part of prison populations, they represent one of the most important – and complicated – health concerns for modern correctional systems.

People with developmental disabilities, in particular, have become over-represented in courts and in prison populations (Ericson & Perlman, 2001). Depending on the state, as many as 38% of prisoners have diagnoses of mental retardation, substantially higher than the prevalence in the general population (Anno, 2001). Many, if not most, prisoners with intellectual disabilities probably also have psychiatric disabilities as well, if prevalence rates in the non-incarcerated population are any guide (Szymanski & King, 1999).

In the United States, up to 75% of prison inmates have a learning disability and read on a fourth grade level (Jordan, 1996). People with developmental and learning disabilities are more likely to be apprehended for crimes, confused by judicial proceedings, and waive their rights (Glasner & Deane, 1999; Linhorst, Bennett, & McCutchen, 2002; Petersilia, 1997).

People with psychiatric disabilities, in particular, are over-represented in prisons (Human Rights Watch, 2003; Lurigio, 2001; Metzner, Cohen, Grossman, & Wettstein, 1998; Osofsky, 1996). In a meta-analysis of research about the prevalence of mental illness in prisons, results indicate that one out of every seven inmates in Western countries have psychoses or significant depression, and approximately one of every two male inmates and one in every five female inmates are diagnosed with anti-social personality disorders (Fazel & Danesh, 2002).

In 2000, across the United States, 13% of state inmates were receiving mental health therapy or counseling, and 10% were receiving psychotropic (mind or mood altering) medication (Beck & Maruschak, 2001). Almost 33% of male mentally ill state inmates, and 78% of female mentally ill state inmates, experienced some form of physical or sexual abuse before entering prison, compared with 13% of male inmates and 51% of female inmates without mental illness (Ditton, 1999). Human Rights Watch (2003) puts the number of people with mental illness in U.S. prisons at between 200,000 and 300,000.

The Vermont Prison System

In 2000, 13,625 Vermonters were in the Vermont corrections system, including those on probation, parole, furlough, and others in community settings. One out of every seven males between the ages of 18 and 21 were under the supervision of the Vermont DOC. Of the total number of adult Vermonters in corrections, 1,610 were incarcerated in prison (VT DOC, 2000).

Vermont has nine adult prison facilities around the state. They include:

1. Northwest State Correctional Facility – St. Albans
2. Northeast State Correctional Facility – Newport
3. Chittenden Regional Correctional Facility – South Burlington
4. Caledonia County Work Camp – St. Johnsbury
5. St. Johnsbury Regional Correctional Facility – St. Johnsbury
6. Southeast State Correctional Facility – Windsor
7. Marble Valley Regional Facility – Rutland
8. Dale Women's Facility – Waterbury
9. Southern State Regional Facility – Springfield

(The Springfield facility opened in 2003, after this survey was done. Data from surveys does not, therefore, reflect information from inmates at Springfield.)

Because the demand far exceeds available space in Vermont prisons, 504 Vermont inmates were housed in Virginia prisons (Virginia Department of Corrections, 2002). These facilities include the Haynesville and Greensville Correctional Centers, and the Sussex 1 State Prison.

Matrix Health Systems provided mental health services in Vermont prisons at the time of this research project. Prison medical and dental services in Vermont at the time of this project were contracted out to Correctional Medical Services, Inc. (CMS). CMS provides services in 27 states at 300 sites, with more than 6,000 employees and 450 contracted providers (Correctional Medical Services, 2003).

Methodology

The Prisoner's Health Coalition, with assistance from the Alliance for Prison Justice and funding from the Vermont Developmental Disabilities Council, sent out a questionnaire to every adult prisoner within the Vermont correctional system in the fall of 2002. Questions centered on health care, disability, and treatment received by inmates within the Vermont correctional system.

Approximately 1600 questionnaires were mailed directly to adult inmates in prison settings in Vermont, and to Vermont prisoners in Virginia correctional facilities. Others were left in prison visiting areas, prison libraries, and sent to family members or friends to share with prisoners. A total of 190 responses were received, 177 from the direct mailing, a roughly 11% return rate. This response rate was considered somewhat low, but not unreasonably so, given that no incentive, follow-up, or similar measures for increasing the number of responses were made (Baruch, 1999; Edwards, Roberts, Clarke, DiGuiseppi, Pratap, Wentz, & Kwan, 2002). Thirteen responses were obtained from sources other than the direct mailing; all responses were from prisoners. Three responses were from women prisoners.

Because questions on the survey were open-ended, requiring narrative, written responses, qualitative research analytical methods were employed. Responses were categorized and coded, and themes were developed (Glesne, 1999; Marshall & Rossman, 1999; Maxwell, 1996; Patton, 2002).

Since the survey required written responses, it is likely that response patterns are skewed toward literate prisoners, and inadequately represent the ideas and perceptions of prisoners with learning, psychiatric, and intellectual disabilities. This is of concern, since the voices of such prisoners, like the voices of people with those kinds of disabilities in Western culture generally, often go unheard (Martel, 2004; Smith, 1999a; 1999b; 2001). Still, given that much research to date regarding people with disabilities in prison has been quantitative, this paper is at least one step in the direction of giving voice to the experiences of people in prison (Quotes in the text from inmate responses are verbatim. Spelling and other errors have not been corrected, intentionally).

Seeing a Nurse or Doctor in Vermont Correctional Facilities: "Wait Wait Wait"

In prisons throughout the Vermont correctional system, the time to see medical personnel seemed much too long to prisoners, according to respondents in this survey. One inmate described the process of submitting a "Correctional Medical Services Health Services Request Form":

A prisoner seeking a visit with a doctor or nurse at this facility is required to deposit a "sick slip" in a box located at the entrance to the chow hall, and access is available only during meal times. It has been my experience that such requests take 5 or 6 days, but other prisoners report much longer waits. There are no provisions for medical emergencies. They tell you, 'put in a sick slip.'

Other inmates in the survey reported that the wait to see medical personnel varied from two days to 10 days or two weeks, or longer. A total of 92 inmates reported the amount of time they needed to wait to see a doctor. 28 prisoners reported waits of 2-4 days to see a physician, and 33 reported waiting 5-13 days to see a doctor. Many prisoners throughout the Vermont prison system noted waits of several weeks – 31 prisoners said they had to wait at least 14 days, or more, to see a doctor. Numerous inmates reported a month and more of waiting.

Several inmates noted here that, because of the substantial time lag between when they request medical attention and when they were actually seen, the illness, injury, or other difficulty often resolved itself without medical intervention. Some inmates said that they had not been able to see a physician at all, in spite of numerous requests. This, they conjectured, might have been because the physician believed the problem was no longer present. Lengthy waits for medical attention were particularly frequent for mental health issues. A Newport inmate noted that, "It's extremely difficult to see any psyche [sic] doctors."

At the Marble Valley facility, a prisoner noted that he had Hepatitis C, for which he had been receiving treatment on the outside. At prison, however, "...the state decided to forego my treatment." This prisoner's bunkmate, a diabetic, was unable to obtain insulin on his arrival until he saw a physician. His sugar level was dangerously high by that time.

For those Vermont inmates sent to Virginia correctional facilities, the situation did not appear to be much better, according to respondents in the current project. Inmates in Sussex I State Prison in Virginia reported waits of 1-4 weeks to receive medical attention. After seeing a physician, prisoners said that it might take another 7 days to receive prescribed medication. Inmates incarcerated in Virginia asserted that Vermonters got less medical care, and care of poorer quality, than Virginians, perhaps because of financial considerations. Another Virginia prisoner commented that there was no medical staff available on Wednesdays, weekends, or holidays.

Seeing a dentist also seemed to take a long time to prisoners, based on responses to the survey. Of the 10 responses received that mentioned wait times for dental care, the shortest wait was two months (for an extraction). The longest wait for care was 5 years (for dental cleaning).

One inmate, very concerned about his dental care, said that

It seems to me that they are more concerned with pulling teeth (because its cheaper) than filling in a few cavities. And they wait for so long that the cavities become so bad that they have to fill them! That's great! I lose part of my body so they can save money.

Treatment Of Medical Problems: "Get Real I'm In Jail"

In this survey, prisoners throughout Vermont's correctional system reported difficulty getting what they felt to be appropriate medical care. For example, in the present study, a number of inmates reported that they were unable to obtain any treatment for their Hepatitis C condition. This finding was a cause for concern for prisoners and prison rights activists, not just in Vermont, but also throughout the United States. An investigative journalist found that it was Correctional Medical Services, Inc. policy to discourage hepatitis treatment for inmates. The journalist quoted Michigan ACLU director Michael Steinberg as saying that such a practice was deliberate indifference, the legal standard applied to claims that care is constitutionally cruel and unusual punishment (Hylton, 2003).

A St. Albans prisoner who responded to the survey reported that he had a stroke, and was partially paralyzed on his left side. There were no grab bars in the shower to help him stand (in spite of numerous requests), and he said he was receiving no rehabilitation to assist him in recovering.

A prison physician told one St. Albans 60-year-old inmate, with pain in his legs, that he had low potassium, and that he should eat a banana every day. As the inmate wrote, "Get real I'm in jail. I can't get a banana a day."

Numerous inmates reported in the survey that they had not received the same prescribed medications while incarcerated as those prescribed to them outside of prison. Some stated that their medications were simply terminated, while others said that their medications were changed, often to ones that that they felt were not as effective. One inmate in St. Albans reported that he was taken completely off his seizure medication after being incarcerated. Afterwards, he continued to have grand mal seizures. Probably as a result, he believed, he had "trouble remembering things and staying focused..."

In summary, then, inmates in Vermont prisons reported in this survey that their medical care was either inadequate or inappropriate. They stated, either implicitly or explicitly, that much of this seemed to be a function of budget considerations, and that concern for their health was not a priority for prison officials.

Treatment for Mental Illness: "The Institution Has Diagnosed Me With Scitzophrania"

Almost two-thirds (62.1%) of respondents in this study reported having some kind of psychiatric disability. In comparison, the Vermont Department of Corrections (2000) estimates that 32.3% of women inmates have been hospitalized at some point for emotional or mental health reasons.

Prisoners in the current project reported being diagnosed with anxiety problems, schizophrenia, suicidal thoughts, bipolar disorder disorder, Tourette's syndrome, obsessive-compulsive disorder, post-traumatic stress disorder, depression, panic disorder, agoraphobia, social phobia, conduct disorder, schizo-affective disorder, borderline personality disorder, thought disorder, and explosive behavior disorder. Almost a quarter of all respondents (22.6%) stated that they had both learning and psychiatric disabilities. Respondents with learning disabilities and psychiatric disabilities represented more than one-third (36.4%) of all those with psychiatric disabilities. While diagnoses of prisoners in this survey were based on self-report, many reported receiving medication consistent with their reported diagnosis.

Inmates with psychiatric disabilities in Vermont prisons in this study described their treatment as problematic, at best. Some prisoners stated they received no treatment at all. Others received only treatment for some issues, and not others. For example, a St. Alban's inmate who described a complex mix of psychiatric disabilities that include attention deficit hyperactivity disorder, bipolar disorder, Tourette's syndrome, obsessive-compulsive disorder, and post traumatic stress disorder, said that he received only treatment for his bipolar disorder. On the flip side, another inmate described himself as being "overtreated and overmedicated – overdosed..."

Another prisoner reported in the survey that "the therapists would be on there [sic] computers playing games and feel bothered if we ask to talk." An inmate at the St. Johnsbury Work Camp with psychiatric disabilities said that the staff "seems to think I'm using it for a [sic] excuse," a concern raised by a number of prisoners. This inmate went on to say that

When my anxiety hits me bad I need to shut down and its not allowed in the program. When it's high [his anxiety], crowded areas with people bother me and all serious it actually hurts my teeth. And it makes me antsy, irritable, and when this happens to me my actions are not acceptable in this program and I get punished and could be failed from this program or may lead me to have to be kick out with a failer [sic] to do the program.

A woman prisoner at Dale said in her response to the survey that she felt that the therapy she had received in prison was inadequate, because counseling staff "...were only trained in basic skills."

A Vermont inmate serving time in Virginia noted in this study

that because of mental health problems I have been placed in seg. [segregation] and a super max in VA since 1999. They said that I can't be trusted. Instead of giving me the proper treatment they are leaving me in a prison where you get minimal treatment.

According to prisoners who responded to the survey, being sent to Virginia, in and of itself, may be counter to appropriate treatment plans for some inmates. One inmate in Virginia said,

Further is the matter of the Vermont DOC sending prisoners to VA with medical defficenties such as high anxiety/depression which are only severely aggravated by this transition. I myself do suffer these medical problems and I'm being forced by the DOC to stay in VA for the duration of the VT 6 year prison sentence, even against two medical doctors requests to not send me here.

These kinds of reports were substantiated by a study done by Human Right's Watch (2003). At Chittenden Community Correctional Center, they found that

...mental health staff... is limited to a part-time psychiatrist and two counselors. Prisoners with mental health needs have no access to group therapy, infrequent access to counselors, and many report they are routinely provided ample opportunity to self-mutilate... the correctional center was not built to deal with seriously mentally ill prisoners (p. 42).

The Human Rights Watch report also noted the long waits experienced by inmates to obtain mental health services.

Suicide in Vermont Prisons: "They Did Nothing to Help Me"

The rate of suicide in prisoners is substantially higher than in the general population (Hall & Gabor, 2004). Suicide has long been a concern in Vermont prisons for prison rights activists. According to Vermont Department of Correction (2000) statistics, there were 446 suicide attempts in Vermont prisons in the 10-year period ending in 2001, an average of 44.6 attempts annually, almost one attempt every week. During that time, six inmates succeeded in killing themselves. In 2003, three inmates killed themselves in the course of a month, and a total of five committed suicide in that year (Mertz, 2003; Ring, 2003).

This research project found that many prisoners were concerned about suicide – both for themselves and others. One prisoner said:

When I first came in to DOC I was very suicidal. I cut myself wanting to blead [sic] out overnight – thank God it never worked! I ask over and over for them to help me get read [sic] of the bad feelings. But they kept blowing me off. I was kicked by the officers in St. Johnsbury, just because I was out of my head and would not eat!

This prisoner felt that, instead of receiving treatment, he had been "stored away."

The 2003 Human Rights Watch report notes that one female prisoner in Vermont stated

I'd put a slip in on Sunday night for suicidal thoughts. They'd get it Monday and it'd be  three weeks before they see you... They'd just look at you like 'that's dumb,' and not give you any mental health counseling (p. 44).

According to Human Right's Watch, this same Vermont prisoner "slit her wrist several times, slammed sharpened pencils into her arms, and even carved her son's initials into her left arm" while in prison (2003, p. 44).

Medication For Psychiatric Disabilities: "I Think I'm Losing My Mind"

On entering prison in Vermont, inmates reported in this study that medications to address psychiatric or mental health concerns were often not available immediately, or were changed abruptly. The present study found that 40.8% of people with psychiatric/mental health needs reported that their medication was changed on entering prison.

One St. Alban's inmate with anxiety problems reported in the present survey that he was prescribed (on the outside) the kind of medication likely to result in withdrawal and relapse if abruptly withdrawn. On entering prison, he was told he could no longer receive this kind of medication. Since then, he had been prescribed seven different medications. Another St. Albans prisoner, diagnosed with anxiety disorder and schizophrenia, was also abruptly withdrawn from the medication he was receiving in the community. He said that "This resulting [sic] to me being placed in D-Unit strip cell several times." (A strip cell is used to hold inmates who need close observation. It has lights that are never turned off, and the toilet cannot be flushed from inside the cell. There is no running water. Inmates are normally "strip searched". Personal items are taken, and anything that can be used in a suicide attempt is removed – shoelaces, belts, sheets, etc. There is sometimes a mattress, and possibly a blanket. Inmates in strip cells are often placed in what is called a "blue suit" – a blue smock with Velcro fastenings).

An inmate diagnosed with "scritsophrania" said in his response to the survey that he was going to be force medicated, without being told why. When he sued to find out the rationale for forced medication, he said that "they withdrew the petition."

A St. Johnsbury Work Camp prisoner said that "if I get a bad anxiety attack, I cannot get the proper medication when its happening." An inmate at Marble Valley said that he had a diagnosis of bipolar, and had asked for medication when he was incarcerated. Two months later, he still had not received any medication.

An inmate at the Dale facility in Waterbury, who received psychotropic medication while outside prison, said that he waited 18 days after being incarcerated to see psychiatric staff in order to be able to resume medication for those mental health concerns.

Another prisoner, in Marble Valley, diagnosed with anxiety, depression, and post-traumatic stress disorder, said in his survey response that he had been receiving medication on the outside. On being incarcerated, he "...was forced to detox from my prescribed medications. As a result of the unsupervised detoxification process I passed out and fell twice." He saw a physician 3-4 weeks after falling, was given a splint, and had x-rays ordered. Four months later, he still had not received x-rays, continued to experience pain, and was still not on medication for his psychiatric disabilities. Another Marble Valley inmate said that his court defense suffered because the medication prescribed for him in prison (different from those he'd been receiving on the outside) did not work.

Human Rights Watch (2003) found the same pattern of problems regarding medication for people with psychiatric disabilities in Vermont prisons.

Prisoners With Learning Disabilities: "I Am Illertereate"

Nationally, 70% of federal and state prisoners fell in the lowest two of five literacy skill levels, putting them substantially lower than the literacy skill level of the general population (Haigler, Harlow, O'Connor, & Campbell, 1994). According to this national report,

These prisoners are apt to experience difficulty in performing tasks that require them to integrate or synthesize information from complex or lengthy texts or to perform quantitative tasks that involve two or more sequential operations and that require the individual to set up the problem (Haigler, Harlow, O'Connor, & Campbell, 1994, p.xviii).

In a Maine survey of incarcerated adults (both men and women) in a county jail, almost 28% reported that they had learning disabilities (Taylor, 1997). This study in Vermont revealed strikingly comparable statistics, with a little over one-quarter (26.3%) of total respondents indicating that they had some kind of learning disability.

According to the Vermont Department of Corrections (2000), 95% of youth under the age of 22, incarcerated in adult facilities, lacked high school diplomas. Of these, about half (48% of the total) had some kind of special education history in school. And incarcerated youth rank in the bottom 20% when tested in basic skills, including reading, written language, and math. In spite of these statistics, the number of student hours in organized instruction programs through the Vermont Department of Corrections actually dropped between 1995 and 1999. Nationally, 75% of inmates in state facilities had not completed high school (Harlow, 2003).

In the study reported here, inmates throughout the Vermont correctional system said they had learning disabilities, describing them in a variety of ways:

- I was in speshal education since I was 6 years old and even was placed in a speshal JR hie scool
-My IQ is not very high.
-I have dyslexia... I was doing really good with those problems in writing and speeking.
-girstmen's syndrom or discraphia.
-I was diagnosed with a learning disability when I was tested at age 11.
-dislexia/mind thinks backwards.
-Yes I am dislexic wich stops me from learning normal.

Again, almost a quarter of all Vermont prisoners who responded to this survey (22.6%) stated that they have both learning and psychiatric disabilities. Of respondents to this survey who had learning disabilities, 86% also reported having psychiatric disabilities. Many also reported having Attention Deficit Hyperactivity Disorder (ADHD),

These results are not unexpected: in a small Swedish study of 63 prison inmates, 41% of whom had dyslexia, those with dyslexia had greater frequency of paranoia, personality disorders, and anxiety disorders than those without dyslexia (Jensen, Lindgren, Meurling, Ingvar, & Levander, 1999).

One prisoner said in his response to the current survey that it was hard "understanding what they want and making myself understood many times." Some inmates denied having learning disabilities, and yet clearly had difficulty writing and filling out the survey. One, inviting people to visit him in prison, wrote: "if you wat to cam to visit you warlca to cam. don't vav to if you want to. I respect avrione alouays."

Cognitive Self Change is a program implemented for violent offenders that begins within the correctional facility 6 months before release back into the community of origin. Within communities the program extends for another year. The program uses cognitive behavioral strategies and centers its efforts on forcing attendees to own up to their own behaviors. Encouragement is given to other attendees to confront each other. The atmosphere is described by inmates as often hostile and tense. Teaching strategies are said to minimize alliances between attendees and encourage feelings that range from isolation to despair.

An inmate in St. Albans who responded to the survey said that he was required to participate in programming. But, he said,

I don't understand it and I receive no help from them. I understand that I am suppose to change my thinking – but the way I am to put it on paper – I just don't understand it!... I've been told that only the smart get through the program.

Another prisoner, from the Windsor facility, said that "the programming environment is hostile and frightening."

Limitations of the study

This project reflects a number of limitations when considering the results. For example, only three responses were from women prisoners. While the number of women in prisons remains low in the United States, it is a population that has seen dramatic growth over recent years (Beck, Karberg, & Harrison, 2002). Nationally, large numbers women prisoners receive significant treatment for psychological and emotional issues (Greenfield & Snell, 2000). Additional research into disability issues and health concerns of women is of substantial importance.

Because the survey required written, narrative responses, the voices of many persons with psychiatric, learning, and intellectual disabilities are likely not included. Personal interviews would address this concern, indicating the need for qualitative inquiry in this area.

Disability determination in this study is based on self-report. This may be seen as a limitation in that it does not reflect objective information about an individual respondent's disability status. As prisoners in the study noted, they were perceived as being malingering by prison workers and officials when they brought up concerns regarding their disability and health concerns. On the other hand, it is an accurate reflection of each person's perception of their individual identity and relationship to cultural and sub-cultural groupings.

Conclusions

"It is a national shame that our prisons and jails serve as mental institutions. It reflects a lack of planning, a failure of public commitment, and a single-minded focus on punishment" (Mariner, 2003).

"...police often arrest the mentally ill when treatment alternatives would be preferable but are unavailable" (Abram & Teplin, 1991, p. 1036).

Data from this survey are disheartening. Prisoners felt that health services in Vermont correctional settings were alarmingly slow. Life-threatening and disabling injuries and other health concerns were dealt with only after long wait periods. When health care was provided, inmates felt that it was out of touch with the reality of prison life, and at other times woefully dangerous, more concerned with bureaucratic issues than the needs of human patients. Medication changes appeared to prisoners to be ill advised, based on cost concerns rather than efficacy. Dental services appeared to them to be almost non-existent. Psychiatric services and supports were felt to be inadequate, and frequently delivered by poorly trained non-professionals.

Regrettably, other researchers have found similar situations in other states. This is in spite of the fact that Vermont in many ways a progressive, forward-thinking state, often on the cutting edge of best practices for services for people with disabilities, across many support systems.

According to a national consensus report, the only safety net available for people with psychiatric disabilities is the correctional system. Often, people with psychiatric disabilities are not in prison because they have committed serious crime, but rather "...because they displayed in public the symptoms of untreated mental illness" (Council of State Governments, 2002, p. xii).

The incarceration of people with psychiatric disabilities represents a fundamental failure of the mental health system (Human Rights Watch, 2003; Koyanagi, 2002). One New York researcher asserts that only in rare instances should people with mental illness be incarcerated in prison (Barr, 1999). State correctional departments, systems of services for people with disabilities, educational systems, and the community mental health systems, in Vermont as with those in other states, must redouble their efforts to ensure that persons with psychiatric and other disabilities are not inappropriately incarcerated. In addition, they must ensure that people with mental illness receive appropriate treatment and accommodations while in prison. Appropriate oversight is essential for insuring quality health care (Hunter, 2002).

Regardless of where they are incarcerated, U.S. prisoners with disabilities must receive supports and health care that meets their needs. Article 25 of the United Nations Universal Declaration of Human Rights states that "Everyone has the right to a standard of living adequate for the health and well-being of himself ... including... medical care" (UN General Assembly Resolution 217 A (III), 1948). Prisoners with disabilities deserve no less.

Acknowledgements

Many thanks to Marsha Bancroft, Andrea Barasch, Chris Gagne, and Alan Taplow for their thoughtful contributions and supportive editing of this paper. The Vermont Developmental Disabilities Council and Vermont Protection and Advocacy provided funding for mailing the survey on which this paper is based. This report does not necessarily reflect the opinions of the Council or Vermont Protection and Advocacy.

References

Abram, K. & Teplin, L. (1991). Co-Occurring disorders among mentally ill jail detainees. American Psychologist, 46, 1036-1045.

Abramsky, S. (2003). The shame of prison health. Prison Legal News, 14(6), 10-13.

Anno, J. (2001). Correctional health care: Guidelines for the management of an adequate delivery system. Chicago, IL: National Commission on Correctional Health Care.

Barr, H. (1999). Prisons and jails: Hospitals of last resort. The need for diversion and discharge planning for incarcerated people with mental illness in New York. New York: Correctional Association of New York and the Urban Justice Center.

Baruch, Y. (1999). Response rate in academic studies – A comparative analysis. Human Relations, 52, 421-438.

Beck, A. & Maruschak, L. (2001). Mental health treatment in state prisons, 2000. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics.

Beck, A., Karberg, J., & Harrison, P. (2002). Prison and jail inmates at midyear 2001. Washington DC: U.S. Department of Justice, Bureau of Justice Statistics.

Campbell, J. & Oliver, M. 1996. Disability politics: Understanding our past, changing our future. NY: Routledge.

Cockram, J., Jackson, R., & Underwood, R. (1998). People with an intellectual disability and the criminal justice system: The family perspective. Journal of Intellectual & Developmental Disability, 23(1).

Correctional Medical Services (2003). Home web site. Retrieved November 20, 2003 from http://www.cmsstl.com/.

Council of State Governments (2002). Criminal justice/mental health consensus project. Lexington, KY: Author.

Ditton, P. (1999). Mental health and treatment of inmates and probationers. Washington, DC: Department of Justice, Bureau of Justice Statistics.

Edwards, P., Roberts, I., Clarke, M., DiGuiseppi, C., Pratap, S., Wentz, R., & Kwan, I. (2002). Increasing response rates to postal questionnaires: Systematic review. British Medical Journal, 324, 1183.

Ericson, K. I. & Perlman, N. B., (2001). Knowledge of legal terminology and court proceedings in adults with developmental disabilities. Law and Human Behavior, 25(5), 529-545.

Fazel, S. & Danesh, J. (2002). Serious mental disorder in 23,000 prisoners: A systematic review of 62 surveys. The Lancet, 359, 545-550.

Fine, M. & Torre, M. (2004). Re-membering exclusions: Participatory action research in public institutions. Qualitative Research in Psychology, 1, 15-37.

Galloway, A. (2003).Washington prison health care substandard. Prison Legal News, 14(1), 1-5.

Glasner, W. & Deane, K., (1999). Normalization in an abnormal world: A study of prisoners with an intellectual disability. International Journal of Offender Therapy and Comparative Criminology. 43(3), 338-356.

Glesne, C. (1999). Becoming qualitative researchers: An introduction (2^nd ed.). NY: Addison Wesley Longman, Inc.

Greenfield, L. & Snell, T. (2000). Women offenders. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics.

Groom, B. (1999). Handling the triple whammy: Serious mental illness, substance abuse, and criminal behavior. Corrections Today, 6(4), 115-119.

Haigler, K., Harlow, C., O'Connor, P., & Campbell, A. (1994). Literacy behind prison

walls: Profiles of the prison population from the National Adult Literacy Survey.

Washington, DC: Department of Education, National Center for Education Statistics.

Hall, B. & Gabor, P. (2004). Peer suicide prevention in a prison. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 25, 19-26.

Harlow, C. (2003). Education and correctional populations. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics.

Human Rights Watch (2003). Ill-equipped: U.S. prisons and offenders with mental illness. New York: Author.

Hunter, G. (2002). Medical care still deficient in Texas prisons. Prison Legal News, 13(12), 1-4.

Hylton, W. (2003). Sick on the inside: Correctional HMO's and the coming prison plague. Harper's Magazine, 307 (1839), 43-54.

Jensen, J., Lindgren, M., Meurling, A., Ingvar, D., & Levander, S. (1999). Dyslexia among Swedish prison inmates in relation to neuropsychology and personality. Journal of the International Neuropsychological Society, 5, 452-461.

Jordon, D. (1996). Overcoming dyslexia in children, adolescents, and adults. Austin, TX: Pro-ed.

Koyanangi, C. (2002). Criminalization of people with mental illness. Retrieved April 25, 2003 from http://www.bazelon.org/newsroom/6-11-02crimstatement.htm.

Leone, P., Zaremba, B., Chapin, M., & Iseli, C. (1995). Understanding the overrepresentation of youths with disabilities in juvenile detention. District o Columbia Law Review, 3, 389-401.

Linhorst, D., Bennett, L., & McCutchen, T. (2002). Development and implementation of a program for offenders with developmental disabilities. Mental Retardation, 40, 41-50.

Lurigio, A. J., (2001). Effective services for parolees with mental illness. Crime & Delinquency. 47(3), 446-461.

McDonagh, D., Noel, C., & Wichmann, C. (2002). Mental health needs of women offenders: Needs analysis for the development of the intensive intervention strategy. Forum on Corrections Research, 14(2), np.

Manville, D. (2003). Federal legal standards for prison medical care. Prison Legal News, 14(5), 1-10.

Marshall, C. & Rossman, G. (1999). Designing qualitative research (3^rd ed.). Thousand Oaks, CA: Sage.

Mariner, J. (2003). Prisons as mental institutions: The mass incarceration of the mentally ill. Obtained November 20, 2003 from http://writ.news.findlaw.com/mariner/20031027.html.

Martel, J. (2004). Policing criminological knowledge: The hazards of qualitative research on women in prison. Theoretical Criminology, 8, 157-189.

Maxwell, J. (1996). Qualitative research design: An interactive approach. Thousand Oaks, CA: Sage.

Mbionwu, L. (2001). Special needs populations with mental illness in the criminal justice system. Protection and Advocacy News, 6 (4).

Mertz, C. (2003). Deaths of three Vermont inmates under investigation. Burlington Free Press. Retrieved November 10, 2003 from http://www.burlingtonfreepress.com/specialnews/3.htm.

Metzner, J. Cohen, F., Grossman, L, & Wettstein, R. (1998). Treatment in jails and prisons. In R. Wettstein (Ed.) Treatment of offenders with mental disorders (pp. 211-264). NY: The Guilford Press.

Osofsky, H. (1996). Psychiatry behind the walls: Mental health services in jails and prisons. Bulletin of the Menninger Clinic, 60 (4).

Patton, M. (2002). Qualitative research & evaluation methods (3^rd ed.). Thousand Oaks, CA: Sage.

Petersilia, J. (1997). Justice for all? Offenders with mental retardation and the California corrections system. The Prison Journal, 77, 358-380.

Ring, W. (2003). Lawmakers to investigate allegations against Corrections Department. Times-Argus. Retrieved November 23, 2003 from http://www.timesargus.com/Local/Story/74091.html.

Russell, M. & Stewart, J., (2001). Disablement, Prison, and Historical Segregation. Monthly Review, 53(1) 61-75.

Smith, P. (1999a). Drawing new maps: A radical cartography of developmental disabilities. Review of Educational Research, 69 (2), 117-144.

Smith, P. (1999b). "I know how to do": Choice, control, and power in the lives of people with developmental disabilities. Dissertation Abstracts International, 60 (11) A (University Microfilms No. 9951862).

Smith, P. (2001). MAN.i.f.e.s.t.o.: A Poetics of D(EVIL)op(MENTAL) Dis(ABILITY). Taboo: The Journal of Education and Culture, 5 (1), 27-36.

Smith, P. (2004). Whiteness, normal theory, and disability studies. Disability Studies Quarterly, 24 (2).

Szymanski, L. & King, B. (1999). Practice parameters for the assessment and treatment of children, adolescents, and adults with mental retardation and comorbid mental disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38 (12), 5S.

Taylor, S. (1997). Education within corrections: A study pertinent to Cumberland County. (ERIC Document Reproduction Service No. ED408504).

Teplin, L. (1994). Psychiatric and substance abuse disorders among male urban jaildetainees. American Journal of Public Health, 84, 290-293.

Vermont Department of Corrections (2000). Facts and Figures. Waterbury, VT: Author.

Virginia Department of Corrections (2002). Virginia Department of Corrections Monthly Population Summary, December 2002. Retrieved April 25, 2003 from http://www.vadoc.state.va.us/resources/statistics/research/popsum_03/02dec_exe.htm.

Wilson, M. (2003). America's prisons turn a blind eye to HCV epidemic. Prison Legal News, 14 (8), 1-4.