Allen Frances, M.D.
Prison Or Treatment For the Mentally ill
We should be supporting mental health, not punishing patients.
 

www.psychologytoday.com - March 10, 2013

 

The public revulsion over repeated mass shootings has placed mental health in the spotlight. This is both good and bad.

Bad because focusing on the mentality of the shooter diverts attention away from the lethality of the weapon -- and from the fact that many mass shooters had no history of mental health involvement. We will never be able to predict who will commit random acts of violence, but we can reduce our ridiculously high rates of gun death by having a sane gun control policy.

Good because our current (non)system of mental health care is badly broken and cries out for fixing and better funding. The problems are spelled out by Amanda Pustilnik, associate professor of law at University of Maryland and an expert on the relationship of law, neuroscience, and mental health policy.

She writes:

"Today, our largest mental hospitals are our jails. The jail at New York's Rikers' Island functions as the nation's largest psychiatric facility. Los Angeles' jails -- not its hospitals - are California's largest providers of mental health care. State prisons alone spend nearly $5 billion annually to incarcerate mentally ill inmates who are not violent."

 

"According to the Department of Justice, nearly 1.3 million people with mental illness are incarcerated in state and federal jails and prisons -- compared to only about 70,000 people being served in psychiatric hospitals.

"The current psychiatric hospital inpatient population is only 5 percent of what it was at its height. We have about the same number of psychiatric hospital beds now as we did in 1850. Some of this 'deinstitutionalization' comes from the availability of medication and improved outpatient treatment, but most of the change is no more than a switch of institutions from hospital to prison."

"Every year, tens of thousands of people try in vain to get access to mental health treatment. It can take months just to get an outpatient appointment and people desperately in need are routinely turned away at the hospital door because there is so little funding for psychiatric beds."

"Where has the money for treatment gone? Much of it has been funneled directly into, and wasted on, our prison system. Prisons and jails have taken on behemoth proportions, bloated with nonviolent and even non-offending people who in earlier times would have been treated in hospitals -- we are the poorer for it and no safer."

"The mentally are far more likely to be the victim of a crime or to harm themselves. Their over-representation in the criminal system results from their poor ability to communicate with police, lack of adequate legal representation, self-medication with drugs and alcohol, enacting symptoms in public, and lack of any other place to put them. As a Florida judge pointed out- jails are the one institution that can't say no to admitting someone -- so the mentally ill are dumped there, often without treatment, and then have a criminal record to boot."

"And some mentally ill people spend time in jails without having committed any offense at all. Several states authorize the police to arrest mentally ill people who have not broken any law, simply to promote public order. More commonly, hospitals transfer patients to jails to handle overflow. Even children may be confined in criminal detention centers because there are so few treatment facilities for severely mentally ill children. This reliance on the criminal justice system as a surrogate mental health system wastes life and treasure, and conflicts with basic notions of justice."

"So, why are we so irrational in our misallocation of resources? Why don't we invest instead in proven alternatives to prison, like assertive community-based treatment programs and access to supportive housing?"

"The problem is that housing and treatment sound like 'entitlements' -- while prison sounds like (and is) punishment. As a culture that prizes self-reliance, we are cautious about extending benefits and suspicious of rewarding people for what looks like bad behavior. The punishment of people with mental illnesses who act out in public might also seem to fit with a certain notion of public order and personal responsibility."

"And it fits with our fears: We look at a handful of national tragedies and conclude that mentally ill people are irresponsible and dangerous - that a law-and-order response is appropriate and necessary. With visions of school shooters before our eyes, we don't see the typical mentally ill person- - someone who is mostly likely to be poor, female, and non-violent."

"According to the Bureau of Justice Statistics, three out of four women in state prisons have a mental health problem, compared to just over half of male prisoners. Yet women are not driving the mass violence problem in our country.

"Our current moment is reminiscent of 1998, when New York State Governor George Pataki responded to the tragedy of a schizophrenic man pushing a woman to her death in front of a subway train. 'What can we as a people,' the governor asked, 'do to protect individuals from themselves and to protect us as a society?'"

"It's time to turn that question around and ask how we can protect mentally ill people from our dangerous preference for punishment over treatment, for prisons over hospitals, for cleaning up tragedies rather than preventing them."

"Let's provide effective treatment for people with mental illnesses, not make them the stalking horse of our fears. If we focus on access to treatment instead of punishment, we may all be safer and live in a better society."

 

Thank you, Professor Pustilnik, for a compelling presentation of a national nightmare. "A society will be judged on the basis of how it treats its weakest members." We are failing that judgment in the most shameful and costly way possible.

To reduce gun violence, we must have saner gun control policies AND saner care of the mentally ill. These are not competing alternatives - they are both desperately needed.

My fear is that we will get neither. As Mark Twain said, "history doesn't repeat itself, but it sure does rhyme."

The rhyme here is political inaction. After each tragedy, the politicians hypocritically mourn and harrumph, but wind up buckling under pressure from the NRA, fiscal constraints, and the prison and gun lobbies.

We now have the best chance in decades of breaking out of the all too familiar past patterns, but the smart money is that the politicians will once again take no, or only symbolic, actions and that we will continue the insane military arming of the civilian population and the cruel shunting of the mentally ill to jail. If mass incarceration of the mentally ill could solve mass gun violence, we'd be safe already. But we aren't.

It seems that only the constant toll of repeated dramatic tragedies will eventually shake the complacency and cowardice of a stalemated Congress and the backward looking state legislatures.

Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.