Authors: Dallandyshe Xhaferri and Melissa Ellin
For decades, Albania has sent its mentally ill convicts to the infamous Zaharia prison, an institution focused solely 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.
Zaharia's patients were constantly beaten and abused by prison guards and were often forced to eat food in bags, said relatives of a former prisoner in this institution. The prison, they said, was overcrowded, dirty, infested with mold, rats and cockroaches.
"No one cared about their well-being," said the family of "EQ," who served 10 months in Zahari for domestic violence and was released before 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 sufficient to provide adequate Services to the more than 300 patients within the facility. In 2019, two psychiatrists and two doctors worked in Zahari, and the pharmaceutical service was open only one day a week.
"In this institution, extreme cases of 12 people with mental health problems were observed in the same cell," said Ardita Kolmarku, a lawyer at the Albanian Committee of Helsinki, an NGO that investigated Zaharina. "These citizens were complaining about lack of oxygen."
The Ministry of Justice says that the lack of government spending contributed to the problems in Zahari.
When the government closed Zaharia, it transferred 319 prisoners to buildings four and five within the IEVP Shen Koll near Lezha, renovated at a cost of 97 million lek. Families and lawyers had hoped the move would improve conditions for prisoners, but that has not happened.
Saint Kolli prison, new building, same problems
So far, Shen Kolli has failed to create a unique structure for the administration and treatment of mentally ill prisoners, a senior government official and lawyer said.
Overcrowded and with no places where inmates can socialize with each other, this prison does not help improve the mental health of the inmates.
"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 LM, a police officer at Zaharia prison, who offered his assessment but asked anonymity.
The Ombudsman says that the prison is overcrowded and does not have enough staff to meet the demands of the population, adding that the situation will remain so until a new plan for the treatment of mentally ill prisoners is finalized.
"Working with them [the mentally ill prisoners at Shen Koll] is terrible," said LM "They need doctors, not police."
The current staff at Shen Koll includes only two psychiatrists, two psychologists and six social workers.
"Convicts with mental health problems should be grouped and treated in special institutions that have at least specialized psychiatric Services, that is, have specialized personnel for mental health, have the appropriate training and work in groups." 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 Kolli 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 the rooms do not offer the necessary six square meters of space per person. Many of the prison's problems – including overcrowding – can be attributed to a lack of sufficient funding.
In Croatia, the government spent about 55 euros per day on prisoners in 2019, according to the Council of Europe's Annual Crime Statistics . In 2014, Greece spent about 28 euros per day on prisoners, according to a report by the Quality of Employment and Public Services.
The General Directorate of Prisons in Albania says that it spends 3189 lek - about 26 euros - per day for incarcerated persons. It did not specify whether there is a plan for additional spending to provide treatment for mentally ill inmates.
A possible solution
Currently, in Albania there are 426 prisoners with mental health problems in the prison system and 362 of them have a decision for "compulsory treatment".
“Their mental health makes our job very difficult,” said LM “We cannot treat them like other prisoners because they are violent. They take their medicine every day, but you can't talk to them."
Rreli says that for these prisoner-patients to resocialize and reintegrate into the wider society, the prison needs a staff of doctors specialized for this target group.
"People with mental health problems are a vulnerable contingent, who require different conditions to be treated", said Rreli.
To provide care for mentally ill prisoners, Rreli said the government should designate a facility for treatment. This institution, unlike Zaharia or Shen Kolli, should not have been a prison. Rather, it should function as a mental health rehabilitation facility.
Last November, the Ministry of Justice and the Ministry of Health and Social Protection signed an agreement that calls for the establishment of a "Special Medical Institution" dedicated to this task. The Ministry of Health said that it is drafting a project proposal for the construction of this institution in 2023.
The special institution will provide therapeutic care for prisoners with mental health problems, according to international standards, that is, it will have a professional staff of doctors and psychologists along with the necessary sanitary conditions.
The US approach to the problem
In the United States, the federal and state governments are also trying to figure out the best way to get mentally ill prisoners the care they need.
Experts and advocates say the answer is to stop treating convicted criminals with mental illness as prisoners.
"There is nothing therapeutic about prison," said Elizabeth Matos, executive director of Prisoner Legal Services of Massachusetts. "The idea that you can have real therapy happen in that environment is counterintuitive."
In 2012, when the country last surveyed its population imprisoned for mental illness, it found that 37 percent of federal and state prisoners and 44 percent of county jail inmates suffered from mental disorders at some point in their lives, according to the U.S. Department of Justice.
Civil society has been calling for changes to the federal prison system since at least 2017, when a nonprofit newspaper called The Marshall Project revealed that the Federal Bureau of Justice (FJB) — which oversees prisons — was providing prisoners with little access to mental health resources. The FJB has not commented on the article or made any public announcements about changes to treatment guidelines.
While it's unclear whether the number of inmates with mental health problems has changed, federal prisons, state prisons and county jails each fall under separate jurisdictions, meaning treatment plans vary widely.
Efforts from state to state
Massachusetts is one of two states in the US that does not have a facility run by the Department of Mental Health to treat individuals awaiting trial or who are unfit for trial due to serious mental health problems.
Most states, said Danna Mauch, president and CEO of the Massachusetts Association for Mental Health, transfer sentenced inmates from prison settings to mental institutions where they are treated as patients, not inmates, but serious problems still persist.
Brian Sims, senior medical adviser for the National Association of State Mental Health Program Directors, said forensic psychiatrists, doctors who deal with incarcerated patients, "are struggling every day" to find the best treatment plans for the prisoners.
"They all say in unison, prison is not the place for them," Sims said.
Instead, Sims says, leaders in the field of forensic psychiatry are advocating, first and foremost, diversion programs that will keep individuals with mental disorders out of prisons.
Sims and Mauch say Michigan provides a good example of forensic psychiatry in action. The state sends pretrial detainees who are deemed unfit for trial, as well as those who are found not guilty because of mental problems, to a mental health facility called the Center for Forensic Psychiatry, not to prison.
Debra Pinals, Michigan Department of Health and Human Services medical director of Behavioral Health and Forensic Programs, said the center provides a centralized unit to evaluate the care patients receive.
"This allows for 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 aren't so lucky. They are often sent to Bridgewater State Hospital (BSH), said Pinals, who previously worked for the state. BSH is run by the Department of Prisons, which means it operates as a prison and not as a psychiatric care facility.
Matos said that prisons like BSH perpetuate unhealthy stereotypes for those inside them.
“We have a lot of people who are incarcerated, apparently suffering from untreated mental health issues,” Matos said. “What we end up with is the criminalization of people with mental health issues .”
How to change
Lawmakers and civil society in Massachusetts are currently trying to create policies that would improve the state's treatment of inmates, such as giving control of BSH to the state Department of Mental Health. However, Rep. Ruth Balser, who has unsuccessfully lobbied for years for legislation to do just that, said the change comes as a result of a group effort.
"It's really incumbent on our society to build a stronger mental health care system so people don't end up in the criminal justice system," Balser said.
There's no universal solution, Sims said, but diversion is a good place to start.
“If you're keeping [inmates] there for as long as some of them are languishing in prisons, you're talking about a lot of taxpayer dollars that could otherwise be invested in a treatment strategy,” Sims said.
Attorney Andre Lelling, who led a two-year investigation into Massachusetts state prisons that found the facilities were violating inmates' rights, said the best way to make a difference is to provide more funding to the prison department. of the state. In this way, this institution can get more staff and general resources. But this does not guarantee better treatment for the mentally ill.
"Prisons are under-resourced," Lelling said, "so when they do have resources, whether it's money or personnel, the priority is not going to be mental health treatment."
Massachusetts, however, has made funds available for this purpose. The state added a line item to its 2019 budget called “Behavioral Health and Residential Treatment” to better track the department’s spending on certain categories, including resources for inmates with mental illness. In 2019, the state spent about $1 million, and in the past two years, that figure has increased by about 500 percent to about $5 million, the state budget shows.
But it still isn't enough, Sims said, and most states are "screaming" at 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 treating inmates with mental illness must be a top priority before any meaningful change can occur.
"Some states have it at the top of their agenda and it's all they talk about," Sims said. "There are other states where it's just not on their agenda. It's just what they want to watch right now.”
In Albania, the treatment of mentally ill prisoners does not seem to be a top priority at the moment. It is not a topic often discussed by government leaders and only occasionally makes it into news coverage. Whether or when this will change remains an open question.
