London's Bedlam psychiatric hospital is infamous today for how its staff brutally abused their patients. Founded in 1247, the ornately-designed facility treated the people within its care as if they were freaks and monsters rather than human beings. For a period, the patients were even turned into a literal spectacle, with thousands of "normal" people flocking to Bedlam so they could pay a token fee to gawp at patients for entertainment — or, as one supporter put it, as a reminder that they must "keep baser instincts in check."
Things are arguably better for mentally ill people in 21st century America. Yet a new study by George Mason University's Schar School of Policy and Government, and published in the medical journal BMC Health Services Research, suggests that any improvement may not be as great as we'd like to think. At present, there are 10 times as many people with mental illnesses in jails and prisons than in state psychiatric hospitals.
In other words, we've substituted jails for treatment facilities.
To learn this, the researchers looked at data from all 3,141 U.S. counties and singled out variables that could influence jail population per capita. After analyzing their data, it became clear that, as the report puts it, "counties with smaller populations, larger percentages of individuals that did not graduate high school, that have more health-related issues, and provide fewer community treatment services are more likely to have higher jail population per capita."
"We continue to send people with mental disorders to prison, because there seems to be nowhere else for them to go."
Niloofar Ramezani, assistant professor of statistics at George Mason University and corresponding author of the study, told Salon by email that "to our knowledge, this study is the only national-level study that examines whether the supply of community-based health services, including mental health services, influences size of the jail population in the U.S., while accounting for other criminal legal, public health, and socio-economic factors."
Ramezani believes that the study's "most important finding," is that "one should focus on building up the community's capacity to provide mental health services." Ramezani pointed out that their study also found that "after accounting for the availability of mental health care services, the size of the violent crime problem no longer has an effect to how the jail is used." American society is filling up its jails with mentally ill individuals in a way that, quantifiably, cannot be plausibly linked to any kind of meaningful violent crime problem.
"The challenge is to have a sufficient workforce for supporting the mental health of the communities to help reducing the jail population size (and the overuse of jails)," Ramezani concluded.
Salon reached out to advocacy groups and experts on America's mass incarceration epidemic. They all said the same thing: The report's conclusions are credible — and unsurprising.
"We've known for some time that this country's chief response to serious mental illness is incarceration, a fact that stands out because prisons are so clearly unsuited to treating mental illness," Wanda Bertram, Communications Strategist at Prison Policy Initiative, told Salon by email. "Our organization recently found that even though 43% of people in state prisons have been diagnosed with a mental disorder, only 26% have received some form of mental health treatment, and only 6% are currently receiving treatment."
Bertram added, "The readiness with which our justice system fast-tracks people with mental illnesses into prison, despite knowing that jail and prison settings won't make that person any better, speaks volumes about the system's ability to deliver justice."
Dr. Craig Haney, a psychologist who has studied the psychological effects of incarceration for decades and a psychology professor at the University of California, Santa Cruz, offered some insight into why America tends to incarcerate rather than help people with mental illnesses.
"The structural origins start with the history of two simultaneous trends that began in the early 1970s," Haney wrote to Salon. The first was the widespread closing of publicly-funded mental hospitals "in part on the promise that they would be replaced by more humane community-based treatment, a promise that was never kept" and the second was "the beginning of a decades-long 'tough-on-crime' era in which politicians competed with each other on who could criminalize the most things and impose the longest sentences. So we shrunk our mental health system and increased the size of our prison system."
Bertram also attributed the trend to imprison people who are mentally ill to ideological choices.
"I think the major problem is an ideology that says that if you have some kind of illness, including mental illness, you ought to be the primary person responsible for your own care," Bertram explained. "That's the ideology that props up our healthcare system, where sick people bear extraordinary costs and crushing debts. And it keeps us from asking why mental health services like therapy, psychiatry, and long-term care are not only expensive, but difficult to access." Pointing out that their report revealed roughly half of people in state prisons lacked any kind of health insurance prior to their arrest, Bertram concluded that "we continue to send people with mental disorders to prison, because there seems to be nowhere else for them to go."
Speaking to Salon, Ramezani relayed the views of Dr. Faye S. Taxman, a co-author of the report, on the underlying causes of America's tendency to incarcerate instead of provide health care.
"The issue could be the lack of sufficient funding stream for mental health services as well as not having enough workforce that can support communities in providing mental health services to individuals who need such care," Ramezani explained. "Also, some view all types of crime as dangerous, so that misdemeanors and minor crimes sometimes are treated the same as major crimes in terms of assessing for pretrial detention. Many individuals cannot afford bail and are incarcerated pretrial."
"...politicians competed with each other on who could criminalize the most things and impose the longest sentences. So we shrunk our mental health system and increased the size of our prison system."
Ramezani and the study's other co-authors ultimately argue, as Ramezani put it to Salon, that "more research needs to be done on the type of individuals with mental health issues who are incarcerated and how they are handled. Once we know more about them, their mental health journey, and how their mental health condition is changing over time while incarcerated, we can find better solutions to provide helpful support to them if they end up in jail."
In addition to doing more research, American policymakers need to exercise the "political will" necessary to address mental health issues in a humane and effective way.
"The first badly needed solution is to increase the capacity of community mental health facilities—we need vastly more mental health personnel than we currently have," Haney told Salon.
In addition, Haney said that American policymakers need "to divert mental health problems out of the criminal justice system at the very outset. Currently, when someone is having, or sees someone else having, a mental health crisis, the only response is to call 9-1-1. This typically brings the police and typically results in a criminal justice system (rather than mental health system) response. That needs to stop." And if a case does wind up in the criminal justice system, "so-called 'mental health courts' need to be increased in number. These are courts where, in instances where someone has been brought into the criminal justice system for behavior that has an underlying mental health cause, requiring treatment rather than punishment, they are diverted out of the criminal justice system and into treatment."
Barring that, Haney asserted that "inside the jail and prison system, we need to increase mental health treatment resources to ensure that those mentally ill persons who are still there are receiving appropriate care."
