This diary is part of a series on the problems and issues dealing with mental illness in American society. The are two previous diaries.
Mass Murders And The Mental Health System
The American Mental Health Crisis
There always has been and likely always be a problem in sorting out the concepts of mental illness and criminality. All human societies attempt to control the behavior of individuals. They develop rules about behaviors that are not allowed and establish sanctions for infractions. In administering such sanctions there is often some consideration of the motivation and intent of the offender. Our present notions of explaining some criminal behavior on the basis of mental illness have certain similarities to deciding that a person is possessed by demons. The same issues of individual and personal responsibility for actions are involved.
Our legal systems make some provisions for people charged with major criminal offences to mount an insanity defense. These laws are generally problematic and don't fit easily with medical notions of what constitutes mental incapacity. However, if the people saying that we should never portray mental ill people as likely to be dangerous had their way, then it would become impossible to use mental illness as an explanation for criminal behavior.
Dealing with people who exhibit symptoms of mental illness who commit acts of serious violence gets the focus of public attention. It is one thing to deal with the issue after the criminal act has been committed. It is another to deal with the issue of predicting future criminal behavior and taking steps to prevent it. The incidents of mass murder generate intense debate.
However, the mentally ill people who are or might potentially be involved in incidents of serious violence are a small number of people. A much larger group are people are those who exhibit some symptoms of mental illness and become involved with the legal system as a result of less serious infractions of the law. They make up a significant portion of the people confined in jails and prisons. As part of its series on the problems of the mental health system The Guardian has published a very good article by the sheriff of Cook Co. IL who runs the Chicago jail.
American jails have become the new mental asylums – and you're paying the bill
With dramatic and continued cuts to mental health funding on the federal and local level, county jails and state prisons are where the majority of our mental health care is being administered today. According to the Treatment Advocacy Center, the largest mental health institutions in 44 of our 50 states are jails or prisons. And 10 times as many mentally ill individuals reside in jails and prisons than in state mental health hospitals, where they should.
The conclusion is heartbreaking but no longer undeniable: we have criminalized mental illness in America, and you are paying for it.
While some of the mentally ill population in our jail has been charged with violent crimes, the majority has been charged with non-violent, lesser offenses such as retail theft, trespassing and drug possession. These inmates end up staying because they can't afford to post bail – or because they have nowhere to go. Ultimately, many of them are sentenced to probation. Often, their cases are dropped. Then they're released into the community, and the vicious and predictable cycle repeats.
People are not winding up in jail solely because they are mentally ill. People with mental illness make up a sizable portion of what we term the homeless. It is often a matter of chance which ones continue to sleep under the freeway and which ones are sleeping in jail. There isn't a lot of system or logic to the process. For 25 years I lived just up the hill from Haight St. in San Francisco where large numbers of homeless people hang out and in the adjacent Golden Gate Park. I watched the regular cycles of public pressure to clean up the situation. When the police would go on a campaign to run them out of the park they would be sleeping in the laundromat. This is a pattern that is repeated all over the country.
Thomas Dart's article indicates that Chicago has made attempts to establish some forms of mental health treatment for jail inmates. His focus is on people who are in jail for low level drug crimes who are also mentally ill. That also raises the issue of what has been accomplished by the trend toward increasing crimilization of everything to do with drugs. As he points out, it has essentially led to the crimilization of mental illness. When I worked in the mental health field I spent a lot of time interfacing with the legal system and it was interesting to observe how two people with very similar issues and problems could wind up in one system rather than the other. What has happened in the years since then is that the mental health system has shrunk in size and scope and the legal/criminal justice system has expanded.
The thesis of Dart's article is that dealing with mentally ill people who have not committed serious crimes in the criminal justice system is ineffective in terms of both benefit to the individual and in terms of cost to the tax payer. There is a basic notion that if people are ill they should be in "treatment" and treatment is supposed to happen in some sort of health care setting. What treatment is and where it should happen is easier to define for what we consider to be physical rather than mental illnesses. There are plenty of problems with the general health care system, but there is widespread agreement that things are worse with mental health.
So if not in jail or under the freeway where should the mentally ill be?
Another article in The Guardian series explores this issue.
A safe place to stay: the struggle to find housing for America's mentally ill patients
The initial focus of the article is the long term struggle of a woman to cope with the problems of her schizophrenic adult son. It is a classic story of the revolving door and the tread mill. He has been in and out of jails, hospitals and under the freeway. The article does a very good job of telling her story. It also offers some broader summary information.
1. 20 to 25% of the single, adult homeless population has some form of severe mental illness
2. Hospitals are notoriously overwhelmed by the number of people seeking psychiatric care, in part because the number of available psychiatric beds decreased by 14% from 2005 to 2010
3. The alternative is often incarceration, a common fate for homeless people with severe mental illness. Jails house ten times as many mentally ill people as state hospitals do
They are placing the focus on "psychiatric beds".
A shortage of public psychiatric beds
In 1955, there were nearly 560,000 public psychiatric beds available nationally. By 2010, that number plummeted to about 43,000, and all states had fallen below the expert recommended minimum of 50 beds per 100,000 population.
They talk at some length about supportive housing but that doesn't match up directly with psychiatric beds. I take that term to refer to slots in an acute level treatment facility. The cost there are probably higher than those in jail. The 560,000 public beds in 1955 were almost totally in state hospitals. They were not providing all that much in the way of treatment. I came on that scene 10 years later and most of what was going on there was incarceration that was difficult to distinguish from the incarceration taking place in a low security state prison.
The initial movement of people out of the state hospitals was not a matter of just dumping people on the street. California was one of the foremost states in the process and it was well underway before Reagan ever became governor. The original concept was to move people into supervised community residential settings with support and treatment services and ongoing case management. I was part of that system and it worked adequately for most of the people involved.
Much of that effort in California was focused on depopulating the state hospitals. That task has by now been largely accomplished. There are now only about 5000 people statewide in the few remaining hospitals operated by state government. The responsibility has been shifted to county government. Community residential services for people who never went to a state hospital are woefully inadequate.
The present concept is that psychiatric beds in acute hospitals are intended to provide short term intensive treatment. Once problems and medication are stabilized people are supposed to move into less intensive long term supportive settings. Whether or not the current level of acute treatment beds are adequate to the function for which they are intended is one question. The plausible answer is that they are probably not. But the really striking gap comes for the people who don't belong in the acute hospital and don't belong in jail.
In California prop 13 and the tax rebellion was the beginning of a long term trend is the reduction of all sorts of local government services. Mental health and homelessness are things that have been easy to cut because most people could look the other way. Other than the dramatic incidents that get media attention, there seems to be general public apathy about the situation.