From Banishment to Criminalization: The History of Severe Mental Illness in America

Image: Erin McCluskey, In These Times

by SARAH SIMON                                                                                                         Staff Writer


There is a powerful solace in the use of statistics to measure catastrophe. One sees this phenomenon all the time: headlines displaying the death toll of a hurricane, the number of homicides that happen each year, or how many gallons of oil were spilled into the ocean. Maybe this is because statistics can shift some degree of uncomfortable, negative emotionality to factual certainty. Perhaps it is because numbers provide the illusion of objectivity and, by proxy, closure. Maybe it is because they can simplify intricate issues into a manageable set of definable numbers. Regardless of the exact reason, this is how I will begin—with the more or less manageable, simple, and certain—because the plight of the incarcerated mentally ill is tragic, complex, and painfully grim. We will get there but, for now, the numbers.

Serious mental illness, measured through exhibiting symptoms of schizophrenia, schizo-affective disorder, major depressive disorder, bipolar disorder, or a brief psychotic break, has a base rate of 4% in the U.S. adult population. For the population of incarcerated adults in the United States, the rate of those with serious mental illness is around 16.7% (14.5% of men and 31% of women) for those in jail and around 15% for those in prison. This means that mentally ill individuals are overrepresented by over threefold in the incarcerated population, even after controlling for extraneous variables such as socioeconomic class, race, and education level.  Reflective of this overrepresentation is the staggering fact that the criminal justice system now serves as the primary purveyor of care for the mentally ill in America. Since 1955, we have eliminated 93% of the beds in state psychiatric hospitals. As a result, there are now over 10 times more people with a serious mental illness who are incarcerated than who are hospitalized, with around 35,000 in a mental hospital and 356,000 in prison or jail. Further accentuating this point, in every single county that has a state mental hospital and a state jail there are more people diagnosed with a serious mental illness in the jail than there are in the mental hospital.

Source: Bernard E. Harcourt, “An institutionalization effect, 1934-2001,” Journal of Legal Studies

Once they have been arrested, mentally ill individuals are more likely to receive citations and stay in jail for longer than non-mentally ill inmates. Upon release, those with mental illness recidivate twice as quickly as those without. There are two primary reasons for these patterns. Firstly, jails and prisons are not institutionally structured to care for mentally ill individuals. Due to the scarcity of hospital beds in state psychiatric facilities, mentally ill individuals who commit a petty crime are often detained in jail for long periods of time while waiting for a treatment bed to become available. Additionally, jails and prisons are constructed around security rather than therapy and thus are more disciplinarian in their reactions to disturbances and conflict. This means that manifestations of mental illness are often treated as rule violations and result in citations and punishment instead of clinical care.

The second reason for this disparity is the significant difference between criminal behavior and manifestations of mental illness. Because many mentally ill offenders are not criminal in their intent, they typically do not commit offenses that are serious enough for long-term prison sentences. Among the most common crimes committed by mentally ill offenders are resisting arrest, evading arrest, trespassing, disorderly conduct, petty theft, and prostitution. All of these crimes are misdemeanors, typically resulting in jail time of a year or less. Offenses like these criminalize mentally ill individuals, ensnaring them in what is often referred to as the “revolving door” between incarceration and the street. They commit a crime, are arrested, and are released to the street without proper care or provisions for their mental illness; they then commit another low-level offense, thus landing them back in jail. To compound this problem, many indigent, mentally ill offenders lose their social security and disability benefits once they are incarcerated. The consequence of this is that an already vulnerable population is forced into a more unstable environment, as they are left without food, housing, or adequate medical care for weeks while they re-apply and wait for their benefits to be reinstated.

Even through a purely factual lens, this unjust facet of the criminal justice system is palpably terrible and deeply complex. These statistics, however, are inherently reductive. In order to understand the full scope of this problem and, moreover, how to best remediate it, one must turn to history to grasp how American society reached this point. The arch of this historical narrative is encompassed within the deinstitutionalization of state psychiatric facilities. Deinstitutionalization, which began around the mid-1950’s, is the process that closed down state mental hospitals and resulted in the transinstitutionalization of those who could not afford private long-term care to nursing homes, jails, and prisons. There are three general provocations for deinstitutionalization at this time: the pharmaceutical industry, the media, and the government.

Before the advent of pharmaceutical drugs to treat psychosis and mental illnesses, life for those in mental institutions was what could only be described as torturous. The primary treatment techniques for the management of symptoms and psychotic episodes were electroconvulsive therapy, initiation of insulin comas, and lobotomies. Painful and inhumane, these treatments were often paired with austere living conditions and a lack of basic liberties. In 1954, the invention of the anti-psychotic Chlorpromazine acted as a catalyst for not only outpatient and self-administered care, but also for a shift in the stigma surrounding mental illness. Many psychiatric patients were now able to live independently, and the general population began to see mental illness as a medical problem that required treatment rather than a condition that should condemn a person to life-long institutionalization.

Coupled with the shift in perception that arose from the wide-spread usage of antipsychotics, the media’s powerful reach also worked to turn public opinion more sharply against state psychiatric facilities. Several well-read publications, including Life Magazine and The Cleveland Press, wrote detailed articles exposing the grave atrocities that were occurring within some state mental hospitals. Reader’s Digest wrote an account of  “hundreds of naked mental patients herded into huge, barn-like, filth-infested wards…stripped of every vestige of human decency, many in stages of semi-starvation.” Exposure of these abuses reached a pinnacle in 1975, when Ken Kesey’s 1962 popular book on this topic, One Flew Over the Cuckoo’s Nest, was turned into a major motion picture. By this time, deinstitutionalization was well underway, aided by the humanitarian hand of the American people pushing popular opinion against involuntary commitment to state mental hospitals and towards local outpatient community care.

While the American public’s desire to deinstitutionalize the mentally ill was altruistic in intent, the government’s motivation to shift away from state-run psychiatric facilities was centered around the conservation of money. This began in 1963 when President John F. Kennedy created the Community Mental Health Centers Construction Act to allocate federal funds for the building and operations of community-based care facilities for the mentally ill.  In 1965, the Social Security Amendments of Medicare and Medicaid shifted even more federal funding to cover the costs of healthcare in America. The problem with this initiative was that, due to budget limitations, Medicare and Medicaid intentionally excluded mental healthcare from their coverage. Instead of promoting better clinical care for psychiatric patients, this funding incentivized state governments to transfer care of mentally ill individuals out of state-run facilities and to federally subsidized institutions. Consequently, mentally ill individuals began to be transinstituionalized to nursing homes and psychiatric wings of hospitals or sent into the community to collect social security and disability benefits.

By 1977, only half of the community health care centers promised by President Kennedy had been built. There were just 650 nationwide and they were providing care for almost 2 million patients. In 1981, states were beginning to see a drastic rise in the number of incarcerated mentally ill people. Also in this year, the Omnibus Budget Reconciliation Act used grants to divert money back to state-level operations. Despite great potential to allocate these new resources toward better, much needed funding of state psychiatric care, this worsened the problem. State governments further decreased their funding for mental healthcare, closing down more psychiatric hospitals and halting development of community care centers. They now perceived funding for mental healthcare as being in direct rivalry with funding for food, housing, and other public goods.

“…They commit a crime, are arrested, and are released to the street without proper care or provisions for their mental illness; they then commit another low-level offense, thus landing them back in jail.”

This complex mixture of medical advancements, social justice initiatives, and efforts to reduce government spending has resulted in the crisis that significantly harms 356,000 Americans every day. America is—and has always been—lacking appropriate infrastructure to support its mentally ill population. While neither the statistics that quantify this tragedy nor a historical summary can adequately portray the decades-long suffering and maltreatment of millions of people, their illumination has led to promising change in recent years. Over 27 states now require police officers to undergo training for mental health intervention and response. Over 20 states have jail diversion programs to connect mentally ill offenders who do not pose a risk to public safety with psychiatric and social resources in lieu of a criminal record and jail sentence. The Affordable Care Act, while imperfect in regard to potentially high copayments, now requires mental health treatments to be covered by insurance.

To end this article with the false notion of conclusion would be misleading. While progress is being made, there is no operative solution for this crisis. The statistics presented in this article reflect our current reality, not a past tragedy. The history describes how this reality came to be, not a fictional narrative. Thus, the future that we will help to build must be of a different reality. It must be one that is centric to human rights, pragmatism, empathy, and universal vitality. The harmful disregard for the mentally ill in America is ongoing. We must not push it to the side and pretend as though it is over or is inconsequential. Education about this issue is where we must start. Carry that knowledge into fighting the stigma of mental illness, advocating against mass incarceration, for the right to health care, and for appropriate institutions for treating vulnerable populations.


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