Imprisoning the Mentally Ill

During the early 1960's, President Kennedy signed into law a bill that began the movement known as Deinstitutionalization. The purpose of the new law was to put an end to the tendency to warehouse people with mental illnesses, as well as those with developmental disabilities, including the mentally and physically handicapped. The reason for this was the startling revelations about the poor treatment patients received in the large and anonymous staffed institutions all over the country. Poor treatment included the shocking neglect and abuse of those with serious handicaps. The institutions were so very large and impersonal that most of what happened went unnoticed and uncared about by the public.

In the area of psychiatry, the idea was to move the less severely mentally ill from these large institutions into the community where local treatment centers would be established to provide them with the medical, psychiatric, and social support they needed to be able to live and function.

By the 1970's, the advent of newer and more powerful anti psychotic medications made it possible to move the more severely mentally ill from the large institutions into the community. The basic premise was the same - those with chronic mental illnesses, such as paranoid schizophrenia, would be able to receive their medication, treatment, social support, and training outside of the institution, and be able to live and work in the community. The success of the entire venture was based on the idea of decentralizing mental health services from the ancient huge institutions to the local neighborhoods where patients could live, attend community psychiatric service centers, receive their medications, psychiatric treatment and rehabilitation, and no longer need to be hidden away in state institutions. After all, with the new medications, the worst of the symptoms would abate. These symptoms included hallucinations and delusions that, before medication, caused bizarre behavior that scared many people who did not understand what was happening. Community Mental Health was believed to be a lot less expensive that warehousing people in mental institutions.

Did Community Mental Health Succeed?

The answer to this question is both yes and no. First, community mental health continues to exist but varies from one state to the next. A lot of the variation has to do with funds available to each community. That is part of the problem. Almost from the outset, there were inadequate funds to support the amount and quality of community mental health services available to support the deinstitutionalization movement. This short fall of funds became more acute as the rate of deinstitutionalization accelerated through the 70's, 80's and 90's. In fact, in many states throughout the nation a large number of state mental institutions were closed.

Many psychotic patients were absorbed into the community mental health system in states such as New York where the State Department of Mental Health was provided with the funds necessary to support such local programs as: 1. Day Hospital, 2. Continuing Day Treatment, 3. Transitional Housing in Apartment Buildings staffed with mental health workers, 4. Vocational Rehabilitation and Training, 5. Local Clinics that provide psychiatric services and anti psychotic medications, 6. Support services for those patients able to work at jobs that were not too stressful.

Problems:

Unfortunately, the entire deinstitutionalization movement, along with its associated community mental health programs ran into several difficulties. Among these difficulties that continue to exist are:

1. Scarce Resources.  Many states and communities around the nation had neither the resources nor the will to build adequate community mental health centers. In many other cases, mentally ill patients were discharged from state mental institutions before local communities were fully prepared to provide them with local services.

2. Medication Compliance.  The success of deinstitutionalization rested on the fact that these severely mentally ill people would be compliant with their medications once they were living in their neighborhoods and receiving support services from the local mental health system. However, what was overlooked was that many patients would refuse to continue to take their medications after discharge from the state facilities.

Why Would Patients Refuse to Comply with Taking their Medications?

While all medications have side effects, none are as serious and uncomfortable as those for the treatment of the psychoses. Medications such as Haldol (Haloperidol) control psychotic symptoms such as hallucinations and delusional thinking. They also cause side effects such as Tardive Dyskenesia. This refers to involuntary muscle movements such as tremors, movements of the mouth and face, and even unsightly drooling. Because these anti psychotic medications are major tranquilizers, they cause sleepiness and lack of energy. Embarrassed by the Tardive Dyskenesia and uncomfortable with the need to sleep, many patients simply stop taking their medications. Others, convinced that there is nothing wrong with them, deny the need for medication and refuse to comply.

Many of these psychotic patients "slipped through the cracks" of the system or had no system to fall back on and became homeless. This led to further problems. Even today, it is believed that a significant percentage of the homeless population nationwide is mentally ill.

3.  Substance Abuse.  Along with the deinstitutionalization movement was the rapidly increasing national problem of drug abuse along with the types of drugs of addiction that were extremely inexpensive to acquire. Among those drugs were and still are, Marijuana, Crack Cocaine, Angel Dust, and many others. The types and varieties of drugs have greatly increased into the present and are widely available to drug abusers and addicts.

Many of the chronically mentally ill became victims of drug abuse. The result was that their psychoses became extremely complicated and more difficult to treat. The mental health system began and continues, to discuss and treat the mentally ill with "Dual Diagnoses." The duel diagnoses were such things as "Paranoid Schizophrenia with Drug addiction. Labels became more exotic with the use of such terms as CAMI or Chemically Abusing Mentally Ill, and, MICA or Mentally Ill Chemical Abusers. These confusing terms were supposed to refer to what came first, the mental illness or the drug abuse. In other words while many of those with psychoses used drugs; there were others who became mentally ill as a direct result of using drugs. I remember working with some mental health experts who reminisced fondly about the "good old days of treating nothing but people with pure psychoses and not chemical abuse."

4.  Criminal Activity.  The combination of chronic mental illness along with chemical abuse caused some patients to have difficulty controlling their symptoms, despite taking medications. Some of these patients became either violent or public nuisances leading to their arrest and imprisonment. Others became involved in criminal activity such as theft, in an effort to support their drug habits. Yet others, cognitively impaired by their mental illness and now suffering the damaging effects of drug abuse, fell easy prey to local drug pushers and crooks, who manipulated them into the commission of crimes that landed them in jail and prison.

Imprisonment:

It seems as if the deinstitutionalization movement backfired on itself as large numbers of the mentally ill, arrested for crimes they committed, came before the court system and were found guilty. They were sentenced to long prison terms. In states all over the nation where there was no community mental health system, prisons became de facto mental institutions. Instead of being reintegrated and rehabilitated into the community, the severely mentally ill were once again locked in.

I recall from my days working in a Day Hospital with those with severe mental illnesses that it was often a "toss up" whether a patient arrested by the police for some offense would land in a psychiatric emergency room and be referred for appropriate care, or be brought to the local jail where they would further decompensate. Decompensation refers to a patient suffering from a severe psychosis becoming more ill, symptomatic, and bizarre in their behavior. All too often, this decompensation would be misunderstood by local law enforcement officials and result in conviction and a long prison term.

One of the things that many states in the nation, such as Florida, are learning about is the importance of training law enforcement officials to understand and react appropriately to those with serious mental illnesses. Reacting appropriately means bringing the patient to a local hospital emergency room where they can be evaluated, hospitalized, and treated for their psychosis.

There are multiple studies that show that the severely mentally ill are over represented in jails and prisons throughout the nation. One study showed that 6 to 16 percent of the prison population, nationally, is severely mentally ill. When combined with those on parole or awaiting trial, the numbers are much larger. In addition, while the number of beds in state mental institutions has dropped by as much as 40 and 50 percent in many states, incarceration of the mentally ill in jails and prisons has increased. Studies also show that large numbers of those who are the mentally ill in prison suffer from paranoid schizophrenia. It should go without saying that imprisonment greatly exacerbates the symptoms of this population.

One of the things that happen to many of the mentally ill prisoners is that their illness worsens to the point where they lose all self control, cannot be kept with the general prison population, and are placed in administrative segregation, another word for isolation, where they become even worse in their behavior. The "bad behavior" of these sick prisoners often results in much longer jail terms than their original sentences, further complicating the hopelessness of their situation.

None of this implies that prison officials are unaware of the fact that these prisoners are mentally ill. In fact, there are psychiatrists on staff at federal and state prisons, and medications are administered. If it were simply a matter of administering medications in order to prevent decompensation, there would be no problem. However, helping those with illnesses such as paranoid schizophrenia, involves in depth psychosocial and rehabilitative services that most prisons are not equipped to handle. There is no question that if prisons are supposed to be correctional institutions, then the mentally ill are in the wrong place. The mentally ill do not need "correction" or punishment but help in learning about and controlling their illness. Prison only worsens the situation.

Innocent by Reason of Insanity?

I am not an attorney and am not able to speak in legal terms. However, it has always been my opinion that the term "insanity" is vague and meaningless. I supposed that, in legal terms, "insanity" presumes that a person is not aware of the rightness or wrongness of their behavior. I am not sure that it is a valid term for the simple reason that a person responding to a paranoid delusion that people want to hurt him, or to a hallucination telling him to punch someone, is not able to control their behavior, even if they understand the moral implications of what they are doing. I have seen patients suddenly hit other patients for what seemed like no reason at all. I remember one such situation in the Day Hospital when a large man hit another while they were filing out of a meeting because the first man heard a voice saying evil things about his mother. He believed he heard the man behind him make the nasty comment, turned suddenly, and struck. We learned, later, that he was responding to voices he was hearing. His action was sudden and impulsive, with no time to stop and think things over. Afterwards, he knew he was wrong and, even before, he knew it was wrong to hit anyone. Yet, the combination of his symptoms and his background and history caused him to act violently. Was he insane? No! Was his behavior a result of his illness? Yes!

So, What Do We Do About Criminal Acts?

There are a few cases in which someone with a diagnosis of paranoid schizophrenia becomes violent and causes serious harm. For example, many years ago I had a case of a "folie a deux." What this means that two people living together, both of whom are mentally ill and untreated, form a joint system of delusions or psychotic beliefs. In that case, a mother and adult daughter formed a folie a deux about a third individual in the community. Ultimately, the daughter, suffering with untreated paranoid schizophrenia, became violent and attacked and seriously injured this innocent person in the community. The daughter was sent to trial, found guilty, and imprisoned in an institution for the "criminally insane." The mother, now an elderly woman, and my patient at the outpatient clinic, maintained her daughter's innocence, insisting that the person who was attacked deserved it because the individual was plotting against her and her daughter. Her daughter, despite receiving medications and therapy in the prison, remained delusional and justified in her attack.

Although the rate of violence among the mentally ill is no greater than among the general population, it should be treated differently. If someone is dangerous, as in the case of the daughter, yes, they should remain incarcerated, but in the type of prison devoted solely to the treatment of the mentally ill who have committed very dangerous and even murderous acts. These individuals simply do not fit the profile of the average criminal, whether of the robber or murderer type.

For the remainder of the population with chronic and severe mental illnesses, they need treatment, medication, social support, rehabilitation, and all the encouragement necessary to help them live and function in the community. Prisons are for criminals. Those with mental illnesses are not criminals.

One More Anecdote:

When I was working in Continuing Day Treatment, a more extensive and comprehensive treatment system than the Day Hospital (Day Hospital was for those who had been acutely ill and recently discharged from inpatient hospitalizations), a female patient got into a verbal argument with another patient. Someone on staff called 911 to have the angry woman taken to the emergency room of the local hospital for evaluation. The patient became frightened and wanted to leave. As usual, a police car accompanied the ambulance to the mental health center. When the patient saw the policeman she, in her fright, threatened him. His superior on the force, a sergeant, became just as angry as she was and was intent on arresting her. In fact, his behavior was reminiscent of someone with a serious mental illness. In any case, it took the psychiatrist on staff appealing to and calming the sergeant, to get him to relent and allow the patient to go to the emergency room in the ambulance. She received the necessary evaluation and medication treatment.

This is a good example of how well meaning police persons misunderstand the mentally ill and are too quick to react. This is also how it becomes so very easy for a person with a mental illness to land in jail and prison.

With even newer and more powerful medications for those suffering from psychotic illnesses, there is more hope than ever to help people live, function, and work in the community. More in the way of community mental health services is needed throughout the nation.

Your comments are welcome and encouraged.