FROM PRISONS TO HOSPITALS - AND BACK :
THE CRIMINALIZATION OF MENTAL ILLNESS
Two hundred years ago, American jails were commonly used to house seriously mentally ill citizens. The inhumanity of that system led advocates in the 1800ís to undertake reforms in the care of the mentally ill. Modern mental hospitals run by State governments evolved in mid-20th century America with the promise of professional medical treatment and rehabilitation.
Dramatic shifts in state psychiatric and penal populations have occurred in the last 20 years. For example, in the early 1970ís, Michiganís mental institutions held about 28,000 patients, while its prisons held 8,000. Today there are less than 3,000 patients in Michigan mental hospitals, while the stateís prisons hold more than 45,000 inmates. (1)
Nationally, state mental hospital populations peaked at 559,000 persons, in 1955. (2)
By contrast, 70,000 individuals with severe mental illnesses are housed in public psychiatric hospitals today, 30% of whom are forensic patients referred by the courts.(3)
In the 1990ís, it has become common once again to find the mentally ill in jails and prisons: The federal Bureau of Justice Statistics (BJS), in a 1998 survey, found that 238,800 mentally ill individuals are incarcerated in U.S. jails and prisons.(4) The study indicates that overall, "nearly a third of all inmates reported they had a current mental condition or had received mental health services at some time." Some mental health experts say the number is probably higher, due to under-reporting by people who donít disclose the information or are unaware of their illness.(5)
II. Factors in the migration from hospitals to jail.
The advent of psychotropic drugs in the 1950ís and 60ís, along with growing litigation over poor conditions and abuses in the hospitals, paved the way for states to release, or "deinstitutionalize," large numbers of patients, some of whom had been institutionalized for most of their lives. This plan held great promise for reinstating community membership with appropriate supports for released patients. Often, however, the financial burden and the search for services fell upon families. Today, implementation of comprehensive, coordinated community mental health systems is still far from a reality in most local jurisdictions. This situation is widely seen as contributing to the criminalization of the mentally ill.
State spending lags far behind the need. While the massive shift of mentally ill individuals from mental hospitals to prisons and jails was never intended by criminal justice or mental health officials, its continuation represents a significant failure by these systems. According to the
Bazelon Center for Mental Health Law, total state spending for treatment of the seriously mentally ill is one third less now than in the 1950ís.(6)
III. Criminalization of the mentally ill is costly.
In Florida, mentally ill individuals in jail and prison outnumber those in state mental hospitals by nearly five to one. Minimum care for one mentally ill person for one year in a Florida jail costs $40,000; one year in a state prison cell costs over $60,000 per mentally ill inmate, while intensive community mental health treatment for an individual costs approximately $20,000 per year. (7)
Nationally, state correctional costs per U.S. resident are increasing faster than costs for education and health. Annual costs per resident for prisons doubled from $53 in 1985 to $103 in 1996. State correctional spending increased at twice the rate of State education spending.(8) Among the reasons for increased costs (more lengthy, mandatory sentences, abolition of parole in a number of states, excessive use of incarceration for less serious drug offenses), is the increasing criminalization of the mentally ill, particularly at the state and local level. For example, the Los Angeles County jail system has been characterized as the largest mental health institution in the nation. Probation systems are also impacted. The BJS survey counted 547,800 mentally ill probationers - 16% of the entire U.S. probation caseload.
Overall criminal justice resources are strained when police, courts, probation and correctional staff are poorly equipped to cope with issues presented by mentally ill offenders. Training and collaboration with mental health agencies can improve and streamline justice system responses.
IV. Multiple problems complicate effective service delivery.
The BJS survey found that mentally ill offenders in State prison had experienced an array of serious problems prior to incarceration:
Underserved populations. The so-called "dual diagnosis" population with substance abuse problems as well as mental illness is considered "hard to serve" and is chronically underserved in most communities. This population is considered to be more at risk of violent behavior than mentally ill individuals who are not substance abusers.(9) Some providers are unwilling or unable to work with this more difficult type of individual. Hospital emergency rooms, homeless shelters and jails are often used as "de facto" service centers for troubled, indigent and vulnerable mentally ill individuals. An overloaded system and the lack of adequate health coverage for mental illnesses have severely impacted many individualsí access to treatment.
V. Sentencing Policy Increasingly Lacks Discretion, Inhibits Problem Solving Approach.
Over the last 20 years, as sentencing reforms such as mandatory minimums have given judges less leeway in sentencing, an increasing number of mentally ill individuals have been sentenced to prisons and jails. By eliminating consideration of the factors contributing to crime, and by limiting the range of community-based sentencing options, these policies may inhibit a judicial problem-solving approach that could lead to more appropriate dispositions. The sentencing process should aim to reduce unnecessary incarceration, reserving costly prison space for those who endanger the community.
Alternatives are Often More Effective and Less Costly than Jail. Reduced discretion in sentencing offenders, many of whom are addicted and/or mentally ill, has driven up incarceration rates for these individuals. Many are repeatedly "recycled" through local jails. In response, a fast-growing "drug court" movement has evolved to provide treatment and supervision as an alternative to incarceration for certain drug offenders. More recently, a number of local jurisdictions have created community-based "mental health courts" to provide similar alternatives for mentally ill offenders. Unnecessary use of costly jail and prison resources can be reduced by establishing a range of effective options, including local diversion programs that help defuse crisis situations and ensure that a disturbed mentally ill person will receive evaluation, treatment and referrals as needed.
Provision of essential services can prevent problems that lead to crime and violence. For those who commit serious crimes of violence, public safety concerns may dictate that a mentally ill person should be treated in a secure psychiatric ward or, if necessary, confined to jail and provided appropriate treatment. It should be recognized, however, that some individuals who have committed serious crimes might not have done so had they been receiving adequate and appropriate mental health treatment. Upon release from hospital or jail, follow-up treatment and supervision are essential. Individualized client services can prevent crises that result in crime, and break the "vicious cycle" between jail and the streets.
VI. Prison and Jail: Not a Solution for the Mentally Ill
The classic purposes of incarceration are punishment, deterrence and rehabilitation. Incarceration is intrinsically punishing. It exacerbates symptoms and distress for most mentally ill inmates. The practice of solitary confinement in "supermax" security facilities is devastating to mentally ill inmates (and to many others), and has been condemned by human rights groups.
For deterrence to work, a person must be motivated and capable of avoiding a return trip to jail. Released with minimal provision for treatment and services in the community, many mentally ill individuals are caught in "the revolving door" between jail and the streets. Rehabilitation in jail may be undermined by the harshness and stress of prison life and the lack of adequate mental health care. Subject to abuse and victimization by other inmates and to punishment for breaking the rules, many vulnerable inmates attempt or accomplish suicide. Diversion from the justice system to appropriate treatment and supervision is a far more humane and effective approach to reducing and preventing crime by mentally ill individuals. These citizens deserve the best efforts of mental health and criminal justice systems to remove barriers to treatment, provide other essential services, and end unnecessary criminalization of the mentally ill.