Prison and Mental Illness

"These statistics make it clear that the boom in the prison industry is fed, in part, by the closing of our mental institutions."

There's a lot riding on the "in part" in that sentence. Given 3 times as many in mental hospitals as in prison in 1953 (why 1953 unless someone was artificially setting up the comparison to come out as dramatically as possible?), the percentage would be a lot more than 16 percent if most of the mentally ill were shifted to prison. As I understand it, the large part of the growth in prison population is due to drug-related offenses, drugs that those with their own internal hallucinogens have no need for.

The issue is the difference between not-guilty due to insanity and guilty, but mentally ill. Prison isn't healthy for anyone. So shouldn't everyone be placed in a setting that is healthier than is the case now? I was glad that the young man who shot Reagan could be cared for outside of prison, but you know how many felt that was injustice, as if all of sudden legions of schizophrenics would then become assassins hoping to wind up in mental hospitals instead of prison. Then for people who weren't so crazy as to have been found not-guilty the cries of injustice would be even louder if they didn't go to prison or if so much money were spent on prisons that they became good places for everyone.

Prisoners are lucky to have the 8th amendment, or it would be even worse.

There is an additional misleading statistic in the link to Human Rights Watch. This quote is from there: 'Prisons have become the nations primary mental health facilities,' said Jamie Fellner, director of Human Rights Watchs U.S. Program ...." A statistic used to justify that is that there are three times the mentally ill in US prisons compared to those in mental health hospitals. Yet the length of stay in prison is for years, while it might be weeks in a hospital. So it's likely that the number of patients seen and discharged in a year at a mental hospital is much higher that those in prison.

A clearer picture comes from the overall numbers. Taking 16% of prisoners as having schizophrenia or affective disorders and 0.68% of the US population in prison, that means 0.1% of the US population is mentally ill and in prison. About 1% of everyone in the US is schizophrenic, about 2% have bipolar disorder, and a larger number have major depression. Whoever these 16% of the prison population are, it's a small percentage of everyone with mental illness. To say that we have abandoned primary mental health care to prisons is either rhetorical drama or a lie, depending how kind you want to be.

What is true is that prison is a tough place to be mentally ill. Yet if a man smears feces on his door in prison, what setting will prevent that? Major mental illness takes years of adapting to the symptoms left behind by the best pharmacotherapy. It's not easy in any setting. I'd be all for letting prisoners with mental illness be housed separately where their experience would be healthier, but in saying that I know there's only so much good that will come from that. It would be a higher priority for me that we spend the money for universal health care in the US. There's a much greater chance to help people that way.

The hyperbole of politics is beyond me. If it helps get money for prisons and/or mental health care to pretend that we now put a large number of people in prison who used to go to mental hospitals, fine. It's not true though.

As DavidD points out, the roughly equal proportions of incarceration seem to be a coincidence stemming from several factors rather than primarily resting on the reduction of institutionalization once you look at the numbers. In addition to increasingly harsh sentencing for drug-related crimes, psychiatric treatments have vastly improved (CBT, almost every known effective anti-depressant and anti-psychotic drug, etc), diagnostic criteria have shifted, and crime rates have fluctuated in the intervening period.

The 16% of prisoners appears to be from this survey http://www.ojp.usdoj.gov/bjs/abstract/mhtip.htm and corresponds to prisoners who had been treated for or diagnosed with any mental or emotional condition and constitutes an obvious decline in the incidence of incarceration of some form of the mentally ill compared with the '53 figures. Mental institutions should be for those who pose a treat to themselves or others as a direct consequence of their illness - I'm guessing that isn't the case for a good portion of that 16%. For those whose mental illness wasn't the cause of the behavior for which they are incarcerated, they deserve effective mental health treatment while incarcerated, but also to be punished according to the law. Also, as the survey notes, mentally ill inmates are more likely to have committed violent or property crimes than other inmates. The US incarceration rate is ridiculous and deinstitutionalization did create some problems (particularly homelessness for some of the severely ill, but IMHO, it remains a vast improvement in how mental health issues are treated in the US), but I don't think the kind of shift being described occured.

While it's certainly true that the mental health system is failing a lot of patients, it is not as stark as those numbers would have you believe.

ClinkShrink, a blogging forensic psychiatrist who works in a prison, wrote about this very thing not long ago.

http://psychiatrist-blog.blogspot.com/2007/01/mythbusters.html

"...there has been no increase in the relative number of people with mental illnesses in correctional systems. The absolute numbers have increased, but not the proportions. There is an increase in absolute numbers of mentally ill prisoners because the prison population as a whole has increased.

"But the following quote is where [the writer of an NYT op-ed piece similar to yours] really takes a leap. More than one, actually:

-- But the graph poses a number of troubling questions: Why did we diagnose deviance in such radically different ways over the course of the 20th century? Do we need to be imprisoning at such high rates, or were we right, 50 years ago, to hospitalize instead? Why were so many women hospitalized? Why have they been replaced by young black men? Have both prisons and mental hospitals included large numbers of unnecessarily incarcerated individuals? --

"Wow, so many conclusions, so little data! There's nothing in the graph whatsoever that would suggest that there has been a change in how psychiatrists make diagnoses. And it's odd to see a psychiatric inpatient referred to as an "unnecessarily incarcerated individual". They aren't incarcerated at all. The demographics are different in hospitals versus prisons because they are different populations. ...But the biggest thing that bothers me about the transinstitutionalization theory is that it's based on the premise that all psychiatric inpatients are potential criminals who would be in jail but for their hospitalization. This just flies in the face of reality. The majority of psychiatric patients don't become involved with the law, even when they are ill."

The incidence of mental illness in the general population is around 20%, so I'm not sure how you concluded that 16% is three times as much. Certain types of illnesses maybe, schizophrenia and bipolar spectrum disorders? Estimates run up to 5% for those two combined.

These kinds of unexamined correlational charts only serve to perpetuate the stereotype of mentally ill people as violent, irrational people to be feared and locked up. Please don't spread the stigma. But thank you for bringing up the topic of deinstitutionalization, as it's always great to be able to discuss that.

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