Imprisoning the Mentally Ill
Allan N. Schwartz, LCSW, Ph.D.
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.