"The debacle of deinstitutionalization continues to worsen with each passing year. In 1955, there were 559,000 individuals in America's state mental hospitals. By 2005, there were only 47,000 state hospital beds left in the country, a number that continues to fall. Numerous studies have documented the tragic effects of releasing hundreds of thousands of seriously mentally ill individuals from state hospitals while failing to ensure that they receive treatment.It's long been clear to me that from an economic perspective, front-end investments in mental health treatment make a lot more sense than waiting for failure and paying the much-greater costs of back-end incarceration when a mentally ill person commits serious crimes. (The latter approach also generates a lot of chaos within the system before they finally get to that point.) About 30% of Texas prison inmates were prior clients of the state's indigent mental health system. But these data seem to show there's a tangible public safety benefit to expanding publicly funded mental health care.
The latest, carried out by Jason Matejkowski and colleagues at the University of Pennsylvania, found that individuals with serious mental illnesses are responsible for 10% of all homicides in Indiana. That translates into approximately 1,700 out of 17,034 total homicides in the U.S. in 2006. Over the past 20 years – during which time the public mental-health system has progressively deteriorated – that would mean 38,000 of 388,311 total homicides. ...
Although the Indiana study is the largest research of its kind in the U.S., two earlier but smaller studies reported that seriously mentally ill individuals were responsible for 10% of homicides in Contra Costa County, Calif., and 29% of homicides in Albany County, N.Y.
Most of these homicides were preventable, since the perpetrators in most cases were not being treated. Nontreatment, a past history of violent behavior and substance abuse are strong predictors of potential dangerousness in this population. We have proven options for decreasing such violence, including outpatient commitment. These programs require mentally ill individuals at high risk for violence to continue taking medication as a condition for living in the community. ...
Another is the misconception that such programs are expensive. In fact, it is our failure to use such laws that is expensive. Repeated hospital readmissions, incarceration costs, and the costs of homicides and other associated violence take a far greater toll on local, state and federal coffers.
The societal cost of not treating the seriously mentally ill is staggering. They constitute at least one-third of the homeless population. Unable to defend themselves because of their disabilities, they are often exploited and victimized. Approximately 5,000 commit suicide each year – one-sixth of all suicides. An estimated 230,000 are in jails and prisons, 10% of all incarcerations. ...
In the end, involuntarily treating people with serious mental illnesses – who, because of their illnesses, are not aware they are sick – does not infringe on their civil rights. The fears of civil libertarians notwithstanding, the paramount civil right of someone who is severely mentally ill should be adequate treatment.
Conversely, they show the current underfunded mental health system may actually harm public safety.
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13 comments:
One of the reasons that homeless mentally ill persons are jailed is that people are afraid of them and call the police and often when the police arrive the situation deteriorates resulting in an arrest.
I also wonder if some of the mentally ill are really able to assist with their defense or make decisions in their own best interest in plea bargaining.
A mentally ill person probably is not a good risk for probation or work release and they are not very likely to be paroled. So my guess is they are released from prison on EOS and then are very likely to return to prison after conviction on a new charge.
We need to figure out how to break this cycle or prevent it from getting started in the first place.
When the "tough on crime" propagandists and the victim's rights groups succeed in budgeting as much money on prevention, dime for dime, as on incarceration, then I'll start believing they really care about victims.
You didn't mention the fact that using the prison system to house the seriously mentally ill, puts both prison staff and the inmate population at risk of violence.
Prison by it's design is not able to treat mental illness. Guards are not trained to treat mental illness. Inmates are not able to protect themselves from the violence associated with mental illness in other inmates.
The ability of Psychologists to treat serious mental illness has improved dramatically since the 1950's and 60's when the State Institutions were shuttered. Back then, an institution wasn't able to do much and perhaps closing them down was an appropriate option - at that time.
Psychiatry has come a long way in the past 50 years. It is a real embarassment that the delivery of psychiatric services is still being shoved off on the prison system.
"One of the reasons that homeless mentally ill persons are jailed is that people are afraid of them and call the police and often when the police arrive the situation deteriorates resulting in an arrest."
About five years ago, I worked for the Texas Department of Mental Health and Mental Retardation. One Friday we got a call concerning a mental health patient who was discharged from Kerrville State Hospital and turned up in El Dorado because that's where the aliens were going to pick him up. People in El Dorado were panicked by a black man mumbling about spaceships. I spoke with Sheriff Doran on Monday morning. We spoke for several minutes before he finally admitted to me that, yes, he'd picked up the guy and, no, he didn't have him in custody. He'd bought the poor fellow a bus ticket to Austin and shipped him the hell out of town.
El Dorado, Doran, mentally ill, aliens . . . insert punch lines here.
Anony said "El Dorado, Doran, mentally ill, aliens . . . insert punch lines here."
You leave it to wide open, but I will refrain don't want to be accused of an attack on Sheriff.
That line good be a good blog start all by its self. LOL
They closed all the looney farms back in the 1980s so these people have to go somewhere... they went to jail.
Sure they are mentally ill.
Right.
John Paul Penry's claim of mental illness went all the way to the US Supreme court, TWICE.
He was headed back a third time when the state offered, and he accepted, life without parole.
Once he was safe from the death penalty he admitted that he had been faking it and was not mentally ill.
It is too easy for these people to fake it so we should just stop worrying about whether or not they are insane. Phychiatry is such a soft science there is no good firm diagnosis that is independant of the person being tested. If mental problems are defined as exhibiting behavior drastically outside the bounds of "normal" then guess what, every killer is insane because murder is not anything close to normal. Besides the death penalty isnt totally about punishing the killer, its also about society showing just how much it despises killers.
Anonymous 03:31 said -
The ability of Psychologists to treat serious mental illness has improved dramatically since the 1950's and 60's when the State Institutions were shuttered.
While I am very sympathetic to the goal of a more humane, enlightened & effective approach to mental health, all interested parties should realize that we have very much 'been to this movie before'.
The leading quote in this comment was chosen because it references a huge institutionalized mental health care system in the USA that was largely closed down about 60 years ago. Younger folks often do not know this story ... a very large, disturbing & painful story.
The USA had reach a situation with mental institutions in which a very large portion, and possibly a majority of all hospital beds were occupied by mental health patients. The cost was exorbitant. The effectiveness was negligible.
Worse, the Soviet Union used their similar institutions to persecute, oppress, and wage psychological warfare against their own people. Our hands were tied in challenging the Soviets, because we had as many people locked up on (ugly) mental wards as they did.
I hope you all feel uneasy about the similarity here with Grits' recent posts on the topics of run-away incarceration, 'tuff on crime' politics, and the patterns of unlawful conviction. There are eerie parallels.
"Fear" was also the main factor in getting folks committed ... usually, simply fear of the odd & different. But politicians milked & stoked the fear just as is done today. (The stigma of mental illness was enormously greater, in generations past.)
The poor effectiveness of the old mental hospitals was less a matter of poor psychological & psychiatric knowledge & skill (and drugs) at that time, and more about massively overburdened institutions which could not afford (or obtain, at any price) the quality care that would have led to better results. 'Patients' were simply 'warehoused' ... behind locked doors, bars on the windows and razor wire around the perimeter.
If we expand the public facilities for the mentally ill, we will run into many of the same issues that overtook us half a century ago. There are not anywhere near the number of qualified professionals to tend the huge numbers of people who would benefit from such care & treatment (and won't be, no matter the education-incentives).
Indeed, a major malfunction of the mental lock-ups was virtually identical to the warning Grits recently raised over the low quality of prison security personnel, and the low pay that ensures poor results. The 'nurses' in mental hospitals were infamous, and for very much the same reasons seen in Texas prisons.
I'll give ya'll the banana (as they say in psych-circles): There is no clean, simple or direct answer to the problems that stem from mental health issues. For one thing, there are too many different kinds of such difficulties, and they are most assuredly not comparable. They require different skills, and different facilities, to address appropriately. The more the State becomes involved, the more lame the 'solutions' attempted.
While some mental illness is 'purely organic' - the direct consequence & expression of something innate going on with the patient - many forms of psychological disturbance also contain significant social ("learned") elements.
For example, a popular illustration of this reality is told in the context of a visit to Bombay, India. While preparing to board a pedicab, the visitor notices a man trotting up the street, weaving somewhat perilously through traffic. He is stark naked.
"What's with him?", the visitor asks his cabbie. "Don't look at him! He's crazy!", comes the reply. "Do you know him?". "No! ... He's naked."
"You know when people go crazy ... they go naked. Don't look at them!"
In India, at the time (some decades past) this was evidently a 'standard circumstance', generally recognized.
When Sigmund Freud performed his seminal studies, he focused on the widespread phenomena of 'anomalous paralysis'. Many middle-class women were partially or completely paralyzed, but without any detectable physical cause. In the years following Freud's work, this particular expression of mental difficulty faded & disappeared.
I will speculate that in the United States, people who 'go mental' understand that ... whereas we do not run naked in the streets, or lie on couch with a leg that cannot move ... we are prone to do something violent. Then everyone will understand, "He's crazy!".
To give law enforcement the benefit of the doubt, one of Torey's law review articles that discussed the imprisonment of the mentally ill cited as one of the causes that police officers take the mentally ill off the streets to _protect_ them. It doesn't take a genius to figure out when someone is mentally ill - the police don't have to take them into the jail. But in the jail there is food, shelter, and potentially some form of treatment (depending on how long they're in there).
I agree that we need to focus on investing money in front-end initiatives. I would raise the question of whether outpatient treatment for the mentally-ill and criminally-inclined would actually reach the intended recipients (b/c they're free in society and don't have to access it if they don't want to), but at least we would know that denial of access to prescription drugs was not causing crime.
The problem that I see with blaming the decrease in mental health facilities is the lack of boundaries between "prison" and "mental facility." Even if we brought back mental facilities, I'm betting they would resemble prisons an awful lot. So we place people in a so-called "mental facility" instead of a "prison" - I'm not sure the outcome for the person nor for society would be any different.
I'm also curious about the mention of "involuntarily treating" the mentally ill - so are we talking about civil commitment? B/c the constitutional rights issues involved in civil commitment cannot be so lightly tossed aside...
RE: Involuntary confinement, in some cases the only question is whether they'll be involuntarily confined in a psych institution or in jail, at least for those deemed incompetent to stand trial. Right now we just warehouse them in jail until a hospital bed opens up to do "competency restoration" so they can stand trial.
The new generation of meds for schizophrenia and bipolar disorder are a lot better than two decades ago, and more can be done outpatient than before, IMO. But that cannot mean we abandon institutionalization altogether, because jail is the only other option. Mental health beds shouldn't be permanent, for most, but they're needed for crisis response in greater numbers than we have them now.
From a 1999 Report on Mental Health by the US Surgeon Gneral:
"Based on data on functional impairment, it is estimated that 9 percent of all U.S. adults...experience some significant functional impairment (National Advisory Mental Health Council [NAMHC], 1993). Most (7 percent of adults) have disorders that persist for at least 1 year (Regier et al., 1993b; Regier et al., in press). A subpopulation of 5.4 percent of adults is considered to have a “serious” mental illness (SMI) (Kessler et al., 1996). Serious mental illness is a term defined by Federal regulations that generally applies to mental disorders that interfere with some area of social functioning."
So 9% of all adults are mentally ill, and 10% of those who commit homicides are mentally ill. Even using the 5.4% stat (if the Penn study is based on the same definition of serious that the the Surgeon General's report references, the rate is less than twice as high as the general population. Let's not brand all mentally ill people as potential killers. What percentage of homicides are committed by men?
Anonymous 12:51
According to the BJS 2005 statistics the homicide offender rates per 100,000 are 11.9 for males and 1.2 for females.
I think your point is well taken that there is not much difference in the incidence of mental illness between homicide offenders and the general population. But I still think that people are conditioned to be afraid of persons that are mentally ill. As a consequence they are more likely to be arrested and not as likely to be placed on probation if they are convicted.
It might be true that some defendants should be found innocent by reason of insanity. But there is one defendant I would like to see strapped between two horses facing opposite directions...with those horses whipped until that woman is divided by divine providence. Insane or not, I can never conceive of a mind set where I might rationalize forgiveness for that woman who hacked off the arms of her child.
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