Really, this is a post for ClinkShrink, but she's been busy with other things. Do you miss her? Let me invite you to listen to Clink's interview on Tier Talk/Corrections One, where she was interviewed about Are Prisons Turning Into Mental Health Hospitals?
Yesterday, I heard Dominic Sisti talk at Sheppard Pratt Hospital about mental health and incarceration: Dr. Sisti is the director of the Scattergood program for the Applied Ethics of Behavioral Health Care at the University of Pennsylvania, where I was an undergraduate just a few (hmmm) years ago. I tweeted the lecture, as best as I could, along with photos of some of the slides, so do check out the hodgepodge of venting that is my twitter feed.
I want to use this opportunity to talk a little about the highly publicized statistics that many many people in jails and prisons are suffering from mental illness. Many believe that correctional facilities are the new psychiatric facilities. Why is this?
~Dr. Sisti and the Treatment Advocacy Center, and many others, will contend that part of the issue is that state hospitals have closed their beds without providing for adequate community services, so this represents a "transfer" of people from one institution to another.
I will add:
~Many people have psychiatric problems -- per NAMI, 1 in 5 in any given year --so we certainly would expect some people in jails and prisons to have mental disorders.
~Mental illness often co-occurs with substance abuse, and substance abuse is a crime in our country.
~Mental illness causes people to be poor, and poor people are more likely to be in correctional facilities, because poverty may lead to crime (eg. stealing food), and poor people can't afford bail or expense defense attorneys so they may stay in jails longer than people with financial resources.
~Our country has the world's highest incarceration rate, and we imprison people we are mad out, not just those we are afraid of. There has to be a better option than imprisoning people for nuisance/non-violent crimes. Many, many people go to jail for "violation of probation" when they can't meet the conditions set by judges -- for many of these folks, showing up is something they just don't seem to be able to negotiate. For some, there is home monitoring, for others there is weekend jail, but there are many people in our jails where incarcerating them amounts to our society cutting off it's nose to spite it's face: a legal record makes it harder to find employment and the cycle of crime continues.
~Incarceration rates have gone up with the "War on Drugs," minimum mandatory sentencing requirements, and an increase in drugs and guns in our society in the decades following the closure of state hospitals.
Sometimes people suffer from mental disorders, and the symptoms of their disorder directly leads them to commit crimes. For example, a person who is delusional and believes someone is going to harm him, so he hurts that person in what he perceives to be an act of self-defense and has no appreciation that this is wrong. Or maybe the logic isn't that clear, but the role of illness is, such as shooting a president to impress Jody Foster.
Sometimes people have symptoms of mental illness that lead them to commit crimes, but with a less obvious link to their illness. For example, people with depression are often very irritable, so someone who is unusually irritable may lose their temper and get into a fight that they would not have if they were not ill.
As mentioned above, sometimes mental illness leads people to conditions that make them prone to certain crimes -- for example someone who is too sick and disorganized to maintain housing may be more likely to be arrested for loitering or trespassing than someone who owns a home.
I mentioned co-morbid drug and alcohol addictions, and those lead people to illegal drug use, belligerent behavior while intoxicated, crimes to obtain money to obtain drugs, job and family loss and many circumstances that may lead to criminal behavior. While many people in jails and prisons are mentally ill, many more have committed crimes related to drug use.
Sometimes people who have mental illness commit crimes for reasons that have nothing to do with their mental disorders.
If someone is obviously very ill and unable to appreciate that their crime was wrong, then many states have a way out of the corrections system: they can plead Not Guilty By Reason of Insanity and be sent for treatment rather than jail. This doesn't always go smoothly, and I'll invite you to read a recent New York Times Magazine article: When 'Not Guilty' is a Life Sentence.
Finally, mental health courts provide for diversion -- people who have been identified as having mental disorders can agree to treatment in order to mitigate their legal problems, and we discussed these courts in some detail in Committed. There are a few caveats to mental health court: the person must admit to having committed the crime, and certain crimes are excluded. When I was researching this chapter, I spend some time in the Baltimore City mental health court with Judge Jack Lesser. While Judge Lesser noted that people were identified for the court, it just mattered that they suffered from a mental illness, there did not need to be a clear link from the illness to the crime.
So what's the answer? Dr. Sisti suggested that we should return to the days of asylums, in the true sense of the word: humane places to care for people who can not care for themselves. See an article in The Atlantic: Should the U.S. Bring Back Asylums? I will tell you that I agree with Sisti: there should be somewhere for people to be when they can't care for themselves. I would add that I want housing for ALL people, not just those with mental illness: that we have people living on our streets is an enormous shame for our country and whenever I hear advocates talk about the homeless mentally ill, I want to groan. In fact I do groan: why don't we care about all homeless people? Why just those with mental illness? But I would add that if we return to asylums, that these institutions must be voluntary, otherwise they simply become human warehouses without an exit and an alternative form of incarceration. If people can be sent to these asylums against their will, society loses an incentive to work towards helping people survive in the least restrictive environment, it becomes much too easy to toss people in these places and throw away the key, and return to the abuses of the past.
So what is the answer? I wish I knew. I'm here today to tell you the problems, but I'll invite you to add your comments and suggestions.
Respectfully, having worked at two State Hospitals in the past year, and watched them be relentless filled with people who are moreso criminals primarily than mental health people cruelly over prosecuted, I don't get this rationalizing how people are being denied essential and acute services when those demanding the admissions have no clue how to triage these inmates!
Oh, and that is the key point to this comment, I didn't read your mention of the recent judicial ruling making all our State Facilities have to take on more inmates and then wade through the morass of figuring out who is genuinely mentally ill, versus who is faking it and just terrorizing patients at whim!
Hope readers look at the link, and then figure out what is really at hand here, is it solely about too many people being incarcerated versus denied genuine care needs, or, a judicial system that once again wants to simplify treatment needs to make it easier for the judges and wardens?!
Again, always fascinating and repugnant how many health care providers stay silent and thus complicit to not challenge poor administrative judgments. Why mental health is a terminally ill profession, based on my humble yet vast experience of near 25 years now.
But, we can naively continue to hope for the best, in a system that really punishes hope and independence because those are not acceptable outcomes for people who crave power and control. Hey, just my perspective, I could be wrong. Just ask those politicians/judges who allegedly represent you how much they are appropriately educated and advised on mental health issues these last, what, 15 or so years?!
Or better yet, maybe talk to real mental health patients stuck in State Hospitals and left to fend for themselves in defacto jails/prisons without appropriate security and consequences for real life crimes going on inside those walls!!!
Yeah, let's read that next column!!!
Joel Hassman, MD
Hi Shrink Rap Team,
My name is Anuj Agarwal. I'm Founder of Feedspot.
I would like to personally congratulate you as your blog Shrink Rap has been selected by our panelist as one of the Top 50 Psychiatry Blogs on the web.
I personally give you a high-five and want to thank you for your contribution to this world. This is the most comprehensive list of Top 50 Psychiatry Blogs on the internet and I’m honored to have you as part of this!
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The lay public and even most psychiatrists have very little idea of what goes on in the lives of the criminally mentally ill. Even in the best cases treatment often amounts to no more than doping up with tranquilizing antipsychotics and warehousing until a sufficient amount of time has passed. Then the person is returned directly to the situation that got them into prison to begin with.
I found myself on the patient end of forensic psychiatry recently with a commitment into a forensic psychiatry ward for a month. It was a major shock to my existence and one I will never forget. This is a plea that we all consider the humanity of the individuals involved. Often it is a combination of personal stressors, mental illness and addiction that leads to prosecutable behaviors. There is often good reason to believe that the offense would never have happened were it not for a mental illness or drug addiction issue. Does that mean that prosecution is not the solution?
This is a question that society has not addressed.
The 'insanity defense' is rarely successful but what is also true is that mental illness is a factor when it comes to sentencing even if there is no mental health diversion and the matter is treated solely as a criminal matter.
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