Prisons have been described as violent places (Fishman, 1934
; Fleisher, 1989
; Human Rights Watch, 2001
; Toch, 1977
) but little is empirically known about the victims of violence and what type of violence is occurring to these individuals and by whom. The findings reported here suggest that prison is a particularly violent place for people with mental disorders. Rates of physical victimization for males with any mental disorder were 1.6 times (inmate-on-inmate) and 1.2 times (staff-on-inmate) higher than that of males with no mental disorder. Female inmates with mental disorder were 1.7 times more likely to report being physically victimized by another inmate than did their counterparts with no mental disorder. When there were statically significant racial/ethnic differences, prevalence was almost always higher among African American and Hispanic persons than among other racial/ethnic groups. Overall, then, inmates with mental disorders are disproportionately represented among victims of physical violence inside prison. However, their rate of physical victimization in prison compares favorably with their estimated rate of victimization in the community. In their study, Teplin et al. (2005)
estimated that more than one-quarter of persons with SMI had been victims of a violent crime in the past year, a rate more than 11 times higher than the general population rates even after controlling for demographic differences. This suggests that the risk of physical victimization for individuals with mental disorder in the community is significantly greater than their risk of being physically victimized in prison.
Before moving on to discuss the implications of our findings, it is important to note several potentially important limitations of the current investigation. First, the estimates presented here focused on physical violence, which is only one form of victimization. These rates of victimization do not include property theft, emotional or psychological victimization, intimidation, or sexual victimization. To accurately and fully characterize the victimization environment inside prison, surveys need to probe these dimensions of victimization as well.
Second, the estimates reported herein should be interpreted cautiously. It is important to note the potential for sample bias. Our random samples ranged from 26% to 53% of the general population among 14 facilities. In absolute terms, a significant proportion of the inmate population is represented but this sample may not generalize to the full population. Non-representativeness was tested in terms of age, race/ethnicity, and length of incarceration and adjusted for in the weighting strategy. Yet these characteristics may not fully predict variation in physical victimization. Our prevalence estimates pertain to a single state correctional system and do not in their levels necessarily generalize to the correctional system of other states or countries. Prevalence rates of physical victimization within and across communities, states, and countries reflect environmental conditions that are shaped by localized factors, such as standard of living, poverty, civil unrest and disorder, demographics, laws, judicial norms, and so forth (Wortley & Mazerolle, 2008
). However, our key substantive finding of relative differences in physical victimization rates between those inmates with and without mental disorder is consistent with findings reported by Human Rights Watch (2003)
and Wolff et al. (2007)
regarding sexual victimization inside prison and Teplin et al. (2005)
and Frueh et al. (2005)
regarding relative victimization in community and psychiatric settings. We are more confident, given the general pattern of greater victimization experienced by people with mental disorders in the community and prison, that the relative differences in victimization prevalence by mental disorder reported herein would generalize to other state correctional systems located in the U.S. Further empirical investigation is warranted to validate this expectation.
Third, other uncontrolled attributes may predict likelihood of victimization. To the extent that inmates who have characteristics that make them victims of physical assault were systematically over- or underrepresented in our samples, the rates reported herein would either, respectively, over or under estimate physical victimization. We account for such uncertainty by estimating confidence intervals, which provide a reasonable (95%) approximation of the range of variation in rates of physical victimization by facility.
Another reason for caution concerns the potential of biased reporting. Audio-CASI is the most reliable method for collecting information about activities or events that are shaming or stigmatizing. It does not, however, correct for bias motivated by the intent to make the facility and its staff members look bad. Inmates and custody staff have complex relations; relations often fraught with tension and hostility. Rarely are inmates given an opportunity to report anonymously on conditions inside prison, including how they are treated by custody staff. This opportunity could be manipulated by false reporting. To guard against this, the consent process stressed the importance of accurate reporting and its impact on the legitimacy of the data and survey. Many of those who chose not to participate in the survey were antagonistic to the “system” or demoralized to the point of disinterest. Participants, by and large, deliberated over questions. They frequently asked the research staff for guidance on how to answer questions about the custody staff because while most were reasonable and fair, some were abusive and cruel. Questions during the survey and the distributions of responses were not suggestive of false reporting. Also, given that the survey instruments were read and completed in real time, involved hundreds of questions, and were completed by hundreds of inmates per day by unit and rapidly over a 2- to 5-day period, systematic strategies for manipulating the survey through false reporting were minimized. In general, systematic false reporting of events or behaviors by custody staff would have resulted in much higher and clustered rates than those reported here.
Finally, our measure of mental disorder was based on self-report to a question about ever receiving treatment for a mental health problem. Approximately one-quarter of the sample reported some prior treatment for schizophrenia, bipolar disorder, depression, PTSD, or anxiety disorder, with rates of treatment for mental disorders ever being as high as 57.6% for female respondents and 22.8% for male respondents. These rates are lower than national rates of mental disorder in prison populations, which were estimated at 73% for females and 55% for males (James & Glaze, 2006
). It is unclear whether and to what extent our sample under-represents mental disorder given the likelihood of undetected and untreated disorder within the prison population. Future research needs to explore this issue with measures of mental disorder that are based on clinical interviews or chart review.
A related limitation concerns the expected correlation between physical victimization inside prison and treatment for trauma, depression, or anxiety as a consequence of the trauma. Our data do not allow us to identify the time pattern, hence causality, between treatment and victimization. In an effort to partially control for the causal sequence, we focused on 6-month prevalence estimates and divided the sample into diagnostic groups with prior treatment for any mental disorder and those with prior treatment for a serious mental illness (i.e., schizophrenia or bipolar disorder — disorders not caused by physical victimization) in an effort to control for the effect of physical victimization in prison on treatment. Future research needs to explore the causality issue in more robust ways.
With those limitations in mind, our evidence suggests that mental disorder is a significant marker for victimization inside prison. Yet as noted by Sparks (1982)
, cross sectional analyses like those conducted herein can identify factors associated with risk but not the causes of these elevated risks. That is, we cannot determine whether those with histories of physical victimization in prison and mental disorder have been transformed by these experiences in ways that fundamentally altered their presentation of self (i.e., making them appear more vulnerable to others) or whether these factors are correlated with an unmeasured trait or behavior of the individual. More longitudinal and qualitative research is needed to better understand the causal and contextual processes surrounding physical victimization inside prison.
Solid epidemiological research on the prevalence of mental disorder within prison populations is critically needed because the violent environment inside prison is likely to increase the need for mental health treatment, because inmates with mental disorder need treatment while incarcerated, because people with mental disorder need to be protected from predators while inside prison, and because people with mental disorder inside prison will eventually return to the community. Returning people with mental illness to the community with more aggravated complicated, and co-morbid mental disorder will challenge the community-based mental health delivery system in ways that must be anticipated.
To reduce victimization of inmates with mental disorders and its consequences, it would be beneficial to develop and implement victim prevention programs for these individuals. Such programs should educate individuals with mental disorders in prison about modifiable risk factors for victimization and help them develop skills that enhance personal safety, improve conflict management, and decrease their vulnerability. It is equally important that inmates be screened for mental disorders and monitored to reduce victimization. Improving detection of mental disorders is the first step to prevent these individuals from becoming victims. Finally, it seems prudent to screen inmates with mental disorders who have been victims of physical violence in prison for posttraumatic stress disorder, a common result of victimization. Posttraumatic stress disorder can aggravate existing mental disorder symptoms and impair treatment outcomes. More attention to and treatment of posttraumatic stress disorder following physical victimization in prison is essential to decreasing the risk of revictimization for inmates with mental disorders.