The incarceration and criminalization of the mentally ill is…well, insane.
Am I being too harsh? Let’ see. The biggest providers for treatment of the mentally ill are LA County Jail, Rikers Island in New York and Cook County jail in Chicago. Two million people a year are incarcerated in 44 states and the District of Columbia, holding more patients than the largest psychiatric hospital.
According to psychiatrist and schizophrenia researcher E. Fuller Torrey in his book, Out of the Shadows, Deinstitutionalization of the mentally ill is a “Psychiatric ‘Titanic’”. He said:
Deinstitutionalization is the name given to the policy of moving severely mentally ill people out of large state institutions and then closing part or all of those institutions; it has been a major contributing factor to the mental illness crisis.”
According to the World Health Organization in Geneva, Switzerland there are about 450 million people worldwide who suffer from “mental or neurological disorders” at some point in their lives. Mental illness ranks 4th l as the leading cause of disease in the world. The WHO says that clinical depression will rank second by the year 2020.
Even with these statistics the WHO goes on to say that nearly 2/3 of people with a diagnosed mental illness go untreated due to the stigma associated with the disease and just plain neglect. “Where there is neglect, there is little or no understanding. Where there is no understanding there is neglect.”
Certainly we have come a long way from the inhumane treatment of the mentally ill in the past. Mental health “treatment” in the 14th century could be more accurately described as torture. It looked like a page out of Dante’s Inferno with the nine circles of hell. In the 18th century Austrian Physician Franz Mesmer invented mesmerism as a cure. This theory was based on the gravitational pull of the moon having a profound affect on our bodily fluids, much like the moon affects ocean tides. This led him to believe that magnetism was the answer so he arranged magnets on key parts of the body.
American colonists diagnosed mental illness as witchcraft but by the late eighteenth century a sense of morality prevailed as spiritualists prescribed work and religious education to soothe the soul.
Erasmus Darling, a rather inept physician, philosopher and scientist and grandfather of Charles Darwin, advocated the “spinning couch” approach. His idea was that mentally ill just needed a lot of sleep and spinning facilitated that. He was not taken too seriously, but noted American physician Benjamin Rush adopted that course of action years later.
Not to put too fine a point on it, the mental health profession has come a long way. However, Republican Newt Gingrich wrote an article entitled, “Mental Illness is No Crime,” and said that “America’s approach when the mentally ill commit nonviolent crimes — locking them up without addressing the problem — is a solution straight out of the 1800s.”
The Deinstitutionalization of the mentally ill was a good idea that went terribly wrong. The ideology that led to the criminalization and incarceration of this population came out of the reliance on drugs (Thorazine in particular) in the place of professional care.
In 1955 Congress created the Joint Commission on Mental Illness and Health that came up with “freeing” mental patients from the constraints of hospitals. A surviving member of that commission later stated that the commission took this ill-fated course of action because of “the sort of overselling that happens in almost every interchange between science and government…Tranquilizers became panaceas.”
The 1961 Action for Mental Health report that came out of the Commission promoted community-based system of “integrated hospital and ambulatory services.” National professionals as well as philanthropic organizations promoted this idea in medicine, academia and politics. E. Fuller Torrey said that, “In effect, approximately 92 percent of the people who would have been living in public psychiatric hospitals in 1955 were not living there in 1994.”
In 1963 the Community Mental Health Centers (CMHC) ACT was created under President John F. Kennedy. This provided subsidies to fund community health care centers. The Young Minds Advocacy Projected celebrated the 50-year mark of this legislation.
According to them it “helped spark a major transformation of the public mental health system by shifting resources away from large institutions towards community-based mental health treatment programs.” They lauded the strides made in patient rights for the mentally ill, and the creation of community-based alternatives to hospitalization.
I will suggest that that celebration was a bit premature.
President Carter was later applauded for establishing the Carter Commission, the first of its kind, which led to the Mental Health Systems Act. It continued funding for federal community mental health centers. The Mental Health Systems Act still proved to be shortsighted in that it did not so much as improve care but fix bureaucratic systemic problems. It also continued funding for federal community mental health centers as well as providing federal grants “for projects for the prevention of mental illness and the promotion of positive mental health.”
E. F. Torrey credits the goals of Carter’s Commission on Mental Health for being well intentioned in their objectives – “maintaining the greatest degree of freedom, self-determination, autonomy, dignity, and integrity of body, mind, and spirit for the individual while he or she participates in treatment or receives services.” He says that this model for treatment has served a significant part of mental health consumers. But he also says:
“Self-determination” often means merely that the person has a choice of soup kitchens. The “least restrictive setting” frequently turns out to be a cardboard box, a jail cell, or a terror-filled existence plagued by both real and imaginary enemies.
Speaking of “least restrictive settings” and open-air sunshine homelessness, president Ronald Reagan comes to mind. His “new federalism”, a transfer of federal power to the state, effectively threw the mentally ill out of the hospitals and on to the streets with the stroke of a pen. He said, “People who are sleeping on the grates…the homeless…are homeless, you might say, by choice.” So not only is it illegal to be sick (as in the prison population), it is a choice.
When Reagan was the Governor of California, the population of state mental health facilities fell from 37,500 in 1959 under Governor Edmund G. Brown, to 22,000 under Reagan.
At that time Dr. Robert Felix, director on the National Institute of Mental Health, had been one of many promoting community care for the mentally ill to replace hospitalization. He said, however:
”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.”
President Reagan cut the budget of the National Institute of Mental Health (NIMH) that caused a decrease in professional psychiatric staff and many of the remaining professionals were assigned to menial duties unrelated to patient care. Under Reagan came the Omnibus Budget Reconciliation Act (1982) that merged mental health resources into block grants to the states allowing them discretion as to where they put their dollars. Many states simply funded existing mental health programs that were already failing.
Reagan, the film actor that became president, is celebrated as a great communicator and Republican Party idol. For the mentally ill, however, he communicated a “let them sleep on the sidewalks” kind of message. And they did.
But to be fair, we can’t lay blame solely at the clay feet of Reagan. The government was responding to fiscal problems in state hospitals with poor conditions. With the advent of pharmaceuticals to manage clients, mental health professionals began to rely more on drug therapy than clinical care. Their prescription was that the community could take over where they had failed. Then community services failed.
Today as a result of America’s persistent recession, things have gotten worse. According to the National Institute for the Mentally Ill, NAMI, “From 2009 to 2011, massive cuts to non-Medicaid state mental health spending totaled more than $1.8 billion dollars.”
When funds are diverted from services to the mentally ill, jails, law enforcement agencies, homeless shelters and overburdened emergency services in hospitals have to take up the slack.
Dr. Torrey, writing about conditions in the 1990s, said that because civil liberties lawyers won the battle to gain more rights for the mentally ill, it became harder for them to access treatment. He said, “You either have to kill the judge or attempt suicide before the bench.” Also he noted that the definition of mental illness had morphed into a conglomerate of maladies, not specific to the mentally ill.
One mental health consumer reveals:
I have schizo-affective disorder. I used to have a caseworker, access to a counselor and group therapy, which were all part of my plan and helped me stay healthy and well. In July of 2010, due to budget cuts, the clinic here in town closed, and they laid off all the staff. I no longer have a case manager and only have peer support once a month, if I am lucky. I don’t know how I will stay well without the medical care and treatment I need.
NAMI is a rigorous advocate for the mentally ill, but they are not alone. Protection and Advocacy for People with Disabilities, et al, filed a lawsuit against the State of Carolina Department of Corrections. The judge in the case was Michael Baxley who stated outright that of the 70,000 cases that he has adjudicated, this lawsuit was “the most troubling.”
In his 45-page order he wrote, “Evidence in this case has proved that inmates have died in the S.C. Department of Corrections for lack of basic mental health care,” He said that this negligence had been known for ten years. Further, he cited the following:
– there was “disproportionate use of force and solitary confinement”
– limitation of access to mental health resources that contributed to “substantial risk of serious harm…”
– supervision of powerful psychotropic drugs was largely unsupervised
– inadequate treatment records
Attorneys Nelson Mullins, Stuart Andrews and Don Wesbrook said that Judge Baxley basically found “deliberate indifference” of the criminal justice system that amounted to “cruel and unusual punishment” under the state constitution. The state is appealing.
But the criminal justice system is not the only culprit in this mounting crisis. The front-line responders to people suffering from a medical illness with social repercussions have become police officers who unwittingly incarcerate the mentally ill who become casualties of the criminal justice system. Deep funding cuts for this at-risk-population is the complaint not only of consumers, but of law enforcement, as well.
When Gandhi was asked what he thought of civilization he said, “I think it would be a good idea.” I concur; however, human cruelty is not the primary cause of man’s inhumanity to man or the mental health dilemma. Would that the poor and sometimes criminal treatment of God’s “least of these” were that simple. There are many dedicated workers in the mental health care system, but this crisis has many different moving parts.
It is easy for a politically protected middle class of “hard working Americans” to look the other way. Mental illness and homelessness is a double stigma. We are all tempted to think of the homeless as lazy ne’er do wells and drunks. However, on any given winter night there are 76,000 veterans who have served this country sleeping on those “grates” that Ronald Reagan talked about. One third of the homeless are mentally ill.
Is treatment of the mentally ill insane? Locking them up in Rikers Island instead of caring for them in hospitals with trained professionals? It sounds pretty crazy to me. I just know we can do better.
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