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Three years ago, the twenty-something grandson of one of my colleagues was arrested for murder. A confirmed, long-standing, well-diagnosed victim of paranoid schizophrenia, he had been off his meds.
Now he was in full flight on a classic schizophrenic tear. He was angry. He was delusional. He was hearing voices that didn’t exist, and they were threatening to persecute him. He was Merlin, a legendary figure best known as the wizard in the Arthurian legend.
Though there were the usual character testimonials submitted to the Court at sentencing, and professional pleas to place him not in prison but in a psychiatric hospital treatment program, he was tried, convicted and sentenced to life in prison. Before his trial, he was incarcerated in a County jail, afterward in a larger state prison.
Even though his correct medication was recorded in the documents that accompanied him to his lock-up sites, during the entire first year of his incarceration, the only medication he received were tranquilizers, not usually given to paranoid schizophrenics except for short periods to calm them down. Nobody looked. Nobody cared.
While some of the facts in this introduction have been edited to protect the inmate’s privacy, with that predicate it may not surprise you to learn that the treatment of this seriously sick inmate is not the exception; it is, with few exceptions, the rule.
More Americans receive mental health treatment in prisons and jails than in hospitals or treatment centers. In fact, the three largest inpatient psychiatric facilities in the country are jails: Los Angeles County Jail, Rikers Island Jail in New York City and Cook County Jail in Illinois.
In a ground-breaking 2006 report, Human Rights Watch said new federal statistics revealed that the number of mentally ill inmates in U.S. prisons and jails had quadrupled since 2000. And, as is true of inmates all across the U.S., the numbers of African American and Latino prisoners have grown out of all proportion to the size of their respective racial/ethnic groups.
The Bureau of Justice Statistics (BJS), part of the Department of Justice (DOJ), reported that more than half of all state inmates now report mental health problems. These included symptoms of major depression, mania and psychotic disorders.
In 1998, the BJS reported there were an estimated 283,000 prison and jail inmates who suffered from mental health problems. That number is now estimated to be 1.25 million. The rate of reported mental health disorders in the state prison population is five times greater (56.2 percent) than in the general adult population (11 percent).
In its 2006 Report, the BJS estimated that 705,600 mentally ill adults were incarcerated in State prisons, 78,800 in Federal prisons and 479,900 in local jails.
In addition, research suggests, "people with mental illnesses are over-represented in probation and parole populations at estimated rates ranging from two to four times the general population."
The 2006 report compiled by the Bureau of Justice also reported that 73% of all women in state prisons, 75% of women in local jails, and 55% and 63%, respectively, among men, have mental health problems. In addition, nearly a quarter of women in state prisons and jails have been diagnosed with a psychiatric disorder by a mental health professional.
So here you have an impaired prison population growing exponentially, composed largely of people who should be in hospital treatment programs and not prison in the first place, under the care of workers untrained to handle sick people whose illness can only get worse in prison, and who would much prefer not having to do so, but who can find no alternative to jail.
How did we get here? Why are so many of the mentally ill homeless, living under bridges or in makeshift shelters? Why haven’t they been admitted to hospital-based treatment programs before they get into petty trouble with the law that eventually escalates them into jail.
There is a sharp division of opinion among different segments of the US population regarding who’s to blame. Many fault the prisoners, others think the police and prison authorities simply want to accrue more power.
The fact is the fault is with neither and both. Prisoners with mental illnesses can’t simply will away their sickness. And some do try to exploit their illnesses to secure greater comforts for themselves. Prison staff has its job to do as well. It’s true that they are often needlessly cruel in getting their work done – like the prison guard who made a bitter joke out of denying sanitary napkins, or offering soiled ones, to mentally disturbed inmates. This is not acceptable behavior; guards need to do whatever is reasonable and legal to maintain order. What do they do?
In recent years, prison officials have increasingly turned to solitary confinement as a way to manage difficult or dangerous prisoners. Many of the prisoners subjected to isolation, which can extend for years, have serious mental illness, and the conditions of solitary confinement can exacerbate their symptoms or provoke recurrence.
“Yet, the Bureau of Justice freely admits that among those incarcerated with mental health problems, only one in three state prisoners, and one in six jail inmates, has received treatment since admission,” Sadhbh Walshe writes in The Guardian newspaper, adding:
“There is no mention in the report about what happens to the majority of mentally ill prisoners who go untreated, but the evidence suggests that they are not just ignored, but actually brutalized by a system that has failed them at every turn.”
According to Human Rights Watch, deficient mental health services in prisons and jails leave prisoners under-treated or not treated at all. Across the country, prisoners with mental health problems face a shortage of qualified staff, lack of facilities and prison rules that interfere with treatment.
“While the number of mentally ill inmates surges, prisons remain dangerous and damaging places for them,” says Jamie Fellner, director of Human Rights Watch’s U.S. Program and author of the 2006 report.
The report says prison staff often punish mentally ill offenders for showing symptoms of their illness, such as being noisy, refusing orders, self- mutilating or attempting suicide. Mentally ill prisoners are thus more likely than others to end up housed in especially harsh conditions, including isolation, that can push them over the edge into acute psychosis.
Mentally ill inmates without their meds often spell trouble for prison staff. Typically, there are no doctors on the premises and no inventory of medicines the guards are authorized to access. The prisoner is yelling, screaming, fighting with other prisoners, generally making life difficult for prison staff. So they turn to what appears to be the weapon of choice: solitary confinement.
Jamie Fellner of HRW quotes a federal judge who called the practice of putting mentally ill prisoners in solitary confinement the equivalent of putting an asthmatic in a room with no air.
Since then, lawsuits against corrections departments in at least 10 states have obtained court orders or settlements.
Steve Leifman says, “We have a criminal justice system which has a very clear purpose: You get arrested. We want justice. We try you, and justice hopefully prevails. It was never built to handle people that were very, very ill, at least with mental illness," says the Florida judge who has campaigned tirelessly to professionalize the care of mental illness in prison or move the entire operation to a far more appropriate setting.
Read some of the heart-breaking testimonies of solitary confinement victims here. If the victims of this cruel treatment weren’t very sick when they entered solitary, no one would be surprised if they were dangerously mentally ill when they were released – sometimes after years of segregation and abuse.
And yet another tragic story of the impact of solitary can be found here.
“Asking prisons to treat people with serious mental illness is pushing round pegs into square holes,” says Fellner. “People who suffer from mental illness need mental health interventions, not punishment for behavior that may be motivated by delusions and hallucinations.”
According to Human Rights Watch, the staggering rate of incarceration of the mentally ill is a consequence of under-funded, disorganized and fragmented community mental health services. Many people with mental illness, particularly those who are poor, homeless, or struggling with substance abuse – cannot get mental health treatment. If they commit a crime, even low-level nonviolent offenses, punitive sentencing laws mandate imprisonment.
The apex of self-delusion came in the form of The Community Mental Health Act of 1963 (CMHA), which was also known as the Community Mental Health Centers Construction Act, Mental Retardation Facilities and Construction Act, Public Law 88-164, or the Mental Retardation and Community Mental Health Centers Construction Act of 1963.
It was an act billed to solve these intractable problems by providing federal funding for community mental health centers throughout the United States. These centers would replace state psychiatric hospitals, thus optimizing the use of tranquilizers – which had been in steady development during the 1950s and 60s, and “preparing the ground” for the array of “miracle” drugs that most of the psychiatric community sincerely believed was just around the corner.
This legislation was passed as part of President John F. Kennedy's New Frontier. It introduced a new piece of psycho-speak into the jargon of psychiatric public policy and led to one of the genuine public health disasters of the second half of the 20th Century.
It was called deinstitutionalization.
Under the legislation, the CMHA provided grants to states for the establishment of local mental health centers, subject to the overview of the National Institute of Mental Health. The NIH also conducted a study involving adequacy in mental health issues. The purpose of the CMHA was to provide for community-based care, as an alternative to institutionalization. However, some states saw this as an excuse to close expensive state hospitals without spending some of the money on community-based care.
Under the CMHA, many patients, formerly warehoused in institutions, were released into the community. However, not all communities had the facilities or expertise to deal with them. In many cases, patients wound up in adult homes or with their families, or homeless in large cities but without the mental health care they needed,
The 2006 BJS report reveals that state prisoners with mental health problems were twice as likely to have been homeless and twice as likely to have lived in a foster home, agency or institution while growing up as those without mental health problems. Prisoners with mental health problems were also significantly more likely to have reported being physically or sexually abused in the past, to have had family members who had substance abuse problems, and to have a family member who had been incarcerated in the past. An estimated 42 percent of state inmates had both a mental health problem and substance dependence or abuse.
Yet, even with meager resources, law enforcement and psychiatric professionals continue to struggle in hundreds of communities throughout the US to create conditions that will improve the lives of the mentally ill who find themselves locked up. They do so knowing that practical public servants typically will assign a zero priorority to spending tax dollars on an idea framed to improve life for the very convicts that turn our jails into noisy, disorganized, expensive, crime-ridden killing fields.
Thus advocates for even the most fundamental mental illness management programs must be perceived by their colleagues as Sancho Panza, tilting at windmills . One of them is Miami-Dade County Judge Leifman, who has worked for many years to get the justice system to do more for the mentally ill than incarcerate them.
Judge Leifman is trying to prevent individuals with mental illnesses who have committed minor non-viiolentklllllllll,,,,. crimes from ending up in jail. He's creating a novel facility in Miami-Dade that will serve as what's known as a "forensic diversion facility."
The program provides a sentencing alternative in cases where the offender has mental health issues. Those entering will begin in a higher-security area, more like a jail, and once stabilized move to a different part of the building for treatment.
Leifman is working to get the justice system to do more for the mentally ill than simply lock them up. His ideas, and to a great extent, the ideas of others who are working on this problem, are centered around trying to ensure that offenders suspected of committing minor non-violent crimes never make it into the prison system to begin with.
All over the US, one can find such pilot or model programs. But few have shown the resources – or the interest – to scale up these experiments.
For the broader community and its political leadership, improving care for mentally ill prisoners has to be among the lowest priorities. Long gone are the euphoric days when local psychiatrists and their political leaderhip could brag about vastly improving medicines for the care of the mentally ill while saving huge amounts of tax dollars on state hospitals no longer needed.
That’s how we got here. In the 1980s, under the directives of three California Governors, including Ronald Reagan, most state-run mental hospitals were shut down – with the promise that mentally ill patients would receive better, more humane care in community-based facilities.
But that left people with mental illness with nowhere to turn, and many ended up in jail, in other words, deinstitutionalization.
What is “deinstitutionalization?” It is the process through which state-owned-and-run psychiatric hospitals were systematically closed down beginning in the early 1980s and their patients encouraged to use “community health centers” (which, for the most part, had not yet been built) and rely for medication on new psychiatric drugs (most not yet developed for clinical testing). Meanwhile, they would make use of existing medications, mostly tranquillizers that are generally not used on patients with, for example, schizophrenia except for short periods of time to calm the patient down.
As early as 1984, the policy that led to the release of most of the nation's mentally ill patients from the hospital to the community is now widely regarded as a major failure. Thousands of people with mental illnesses had no place to live except under bridges or in makeshift shelters. Many were Vietnam vets. They had no treatment, no medicines other than tranquillizers that worked, no support systems, and few who cared whether they lived or died.
Who was responsible? Sweeping critiques of the policy, notably the American Psychiatric Association, spread the blame everywhere, faulting politicians, civil libertarians, lawyers and psychiatrists.
Many in the psychiatric community felt optimistic that they would soon develop medications analogous to penicillin – penicillin for schizophrenia and depression and bipolar disease and all the other awful demons and goblins that nature unleashed. Many convinced themselves that these psychiatric wonder drugs had already arrived,
The shrinks weren’t conning anyone, except perhaps themselves. They believed their own story. And their enthusiasm was so overwhelming that before long they managed to convince the politicians in California that they were standing on the brink of a new day: Soon they would be able to tell their constituents that they were able to be tough on crime and save large sums of money at the same time.
Eventually, very powerful people bought into the myth. Topping the list were the three California Governors, and Governors of other states, and the Federal Government to which the “good news” had traveled quickly.
Richard Lyons wrote in the New York Times in 1984, “the politicians were dogged by the image and financial problems posed by the state hospitals and that the scientific and medical establishment sold Congress and the state legislatures a quick fix for a complicated problem that was bought sight unseen.”
He added: “In California, for example, the number of patients in state mental hospitals reached a peak of 37,500 in 1959 when Edmund G. Brown was Governor, fell to 22,000 when Ronald Reagan attained that office in 1967, and continued to decline under his administration and that of his successor, Edmund G. Brown Jr. The senior Mr. Brown now expresses regret about the way the policy started and ultimately evolved. ''They've gone far, too far, in letting people out,'' he said in an interview.”
Lyons quotes Dr. Robert H. Felix, who was then director of the National Institute of Mental Health and a major figure in the shift to community centers, who says now on reflection: ''Many of those patients who left the state hospitals never should have done so. We psychiatrists saw too much of the old snake pit, saw too many people who shouldn't have been there and we overreacted. The result is not what we intended, and perhaps we didn't ask the questions that should have been asked when developing a new concept, but psychiatrists are human, too, and we tried our damnedest.''
The original policy changes were backed by scores of national professional and philanthropic organizations and several hundred people prominent in medicine, academia and politics. The belief then was widespread that the same scientific researchers who had conjured up antibiotics and vaccines during the outburst of medical discovery in the 50s and 60s had also developed penicillins to cure psychoses and thus revolutionize the treatment of the mentally ill.
One of the most influential groups in bringing about the new national policy was the Joint Commission on Mental Illness and Health, an independent body set up by Congress in 1955. One of its two surviving members, Dr. M. Brewster Smith, a University of California psychologist who served as vice president, said the commission took the direction it did because of ''the sort of overselling that happens in almost every interchange between science and government.''
''Extravagant claims were made for the benefits of shifting from state hospitals to community clinics,'' Dr. Smith said. ''The professional community made mistakes and was overly optimistic, but the political community wanted to save money.''
Charles Schlaifer, a New York advertising executive who served as secretary-treasurer of the group, said he was now disgusted with the advice presented by leading psychiatrists of that day.
''Tranquilizers became the panacea for the mentally ill,'' he said. ''The state programs were buying them by the carload, sending the drugged patients back to the community and the psychiatrists never tried to stop this. Local mental health centers were going to be the greatest thing going, but no one wanted to think it through.''
In restrospect it does seem clear that questions were not asked that might have been asked. In the thousands of pages of testimony before Congressional committees in the late 1950's and early 1960's, little doubt was expressed about the wisdom of deinstitutionalization. And the development of tranquilizing drugs was regarded as an unqualified ''godsend,'' as one of the nation's leading psychiatrists, Dr. Francis J. Braceland, described it when he testified before a Senate subcommittee in 1963.
Dr. Braceland, a former president of the American Psychiatric Association who is a retired professor of psychiatry at Yale University, still maintains, however, that under the circumstances the widespread prescription of drugs for the mentally ill was and is a wise policy.
''We had no alternative to the use of drugs for schizophrenia and depression,'' Dr. Braceland said. ''Before the introduction of drugs like Thorazine we never had drugs that worked. These are wonderful drugs and they kept a lot of people out of the hospitals.''
The consensus seems to be that the more intelligent approach to the overall problem is to realize both the limitations and value of the drugs, the importance of combining drug treatment with proper care - either in hospitals or local clinics, depending on the individual case - and that mental illness is a sociological fact that cannot be ignored simply out of a desire to save tax dollars.
Jack R. Ewalt, who directed the staff of the Joint Commission when it was founded in 1955, says now that he remains ''a great believer in the use of drugs, but they are just another treatment, not a magic.''
''Drugs can help people get back to the community,'' he said, ''but they have to have medical care, a place to live and someone to relate to. They can't just float around aimlessly.''
Dr. Ewalt said the 1963 act was supposed to have the states continue to take care of the mentally ill but that many states simply gave up and ceded most of their responsibility to the Federal Government.
''The result was like proposing a plan to build a new airplane and ending up only with a wing and a tail,'' Dr. Ewalt said. ''Congress and the state governments didn't buy the whole program of centers, plus adequate staffing, plus long-term financial supports.''
President Kennedy’s Community Mental Health Act of 1963 (CMHA) was an act to provide federal funding for community mental health centers in the United States. This legislation was passed as part of John F. Kennedy's New Frontier. Though its implementation was patchwork, it led to considerable deinstitutionalization.
In 1955, Congress passed the Mental Health Study Act, leading to the establishment of the Joint Commission on Mental Illness and Mental Health. That Commission issued a report in 1961, which would become the basis of the 1963 Act.
The CMHA provided grants to states for the establishment of local mental health centers, under the aegis of the National Institute of Mental Health. The NIH also conducted a study involving adequacy in mental health issues. The purpose of the CMHA was to provide for community-based care, as an alternative to institutionalization. However, some states saw this as an excuse to close expensive state hospitals without spending some of the money on community-based care.
Under the CMHA many patients, formerly warehoused in institutions, were released into the community. However, not all communities had the facilities or expertise to deal with them. In many cases, patients wound up in adult homes or with their families, or homeless in large cities but without the mental health care they needed
Here then we have the perfect storm: A collection of well-intentioned but seriously flawed assumptions and a large helping of self-delusion used as the basis for a new national public health policy that won the uncritical favor of politicians, drug companies, psychiatrists – even property developers who would build the network of community health centers and lawyers who drew up the deeds and transfers -- but which instead resulted in unspeakable pain and suffering for millions of people with mental illnesses, in and out of prison.
Editor’s Note: Sadhbh Walshe writes a weekly column for The Guardian newspaper on the mentally ill in US prisons and jails. Her series is called “Inside Story: The U.S. Prison System.