Friday, June 04, 2010

Jails, Hospitals, and Mental Health

Happy Friday, everyone. It's been a short week, but with having been sick for the better part of it, it's sort of felt like a long week to me at the same time.

So what's up?

A coworker sent me a link to a new study that came out this month, showing that across the United States there are now more than three times as many mentally ill people in jails and prisons than in hospitals. Frankly, that's just awful.
Let me start off by saying that, as a prosecutor who deals with these cases, my job is supposed to be to see that justice is served. We even have a prosecutorial oath which says as much.
But I'm here to tell everyone that the criminal justice system isn't really designed to deal with the sort of issues that involve the mentally ill. At best, the criminal justice system is designed to accomodate the circumstances that surround mental illness (sort of making exceptions and special rules that can be applied in cases involving mental illness), but one of the underlying, foundational premises for the functioning of the entire criminal justice system revolves around the idea of free will, responsibility, and personal accountability. When people are genuinely incapable of acting rationally or control their own behavior, the criminal justice system has a hard time dealing with them (and I'm definitely not here to say that every case of mental illness automatically prevents a person from controlling their behavior and making logical decisions, but part of my job as a mental health prosecutor involves trying to figure out when I should be holding people accountable for their behavior versus those instances where it really wouldn't be fair or rational to do so, and that can be a hard decisions to make- even qualified doctors may not be able to come to an agreement on such matters. And yes, I do rely upon the opinions and expertise of mental health professionals when making decisions.)
One thing that really discourages me about the results of this study is the simple fact that it shows not only how badly the mental health system is broken, but also the damage that's being caused to not only the mentally ill population in this country, but to the general population at large, as well. A key component of my job is to stand up for the rights of victims, and on the vast majority of cases that put mentally ill people into jail in the first place, somewhere out there there is a victim who has been physically hurt, had their property damaged, their safety threateneed, or their quality of life impacted in some sort of negative way. I really, truly do sympathize with people who struggle with mental illness, but the flip side of the equation is that we just can't expect the general population to put up with socially unacceptable behavior and criminal acts that are committed by people with illnesses. The rights and freedoms of the mentally ill population can't be achieved at the expense of the safety and/or quality of life of the general population. First of all, the general population won't tolerate it, and ultimately, we aren't really seeing a successful integration of the mentally ill into the mainstream population if they're constantly being engaging in behavior that gets them arrested, anyway.
So not only are the mentally ill people being held and treated in facilities which were never designed for treating or housing the mentally ill (and which may expose them to a broader population of defendants and criminals), but they're arriving in these facilities by way of generating more and more problems in our communities which have a negative impact upon the population as a whole.
As I've said before, I tend to think (and I'm pretty sure a lot of people more qualified than myself agree) that the source of some of these problems came with the big push for deinstitutionalization in the 80's and 90's. The thinking at the time was (and still is, among many people) that it was cruel and unfair to deprive mentally ill of their liberty and freedom simply on the basis of an sickness that was in no way their fault. At the time, a number of promising new drugs had been developed, and mental health professionals were gravitating toward the idea that mentally ill people could be successfully mainstreamed into the "normal" population and successfully treated outside of mental health institutions. State and local governments, of course, saw an opportunity to save a considerable amount of money by shutting down mental health institutions, and they moved fairly quickly to shut down facilites and send patients out into the community.
I hasten to add that for a fair number of insitutionalized people with mental illness, this was probably a very good thing.
On the other hand, for patients who didn't want to take their medications, patients who refused to take their medications, patients for whom medications weren't very effective, or patients who simply weren't good at taking their medications (medication regimens can be sort of complicated and strict, after all), problems began to quickly develop (and in a side note, we have a serious problem with a large number of mentally ill people trying to self medicate with street drugs and alcohol, so that's a big issue as well). With unmedicated individuals or individuals who weren't being helped all that much by their meds, a trend began to develop in which their inability to comply with social rules and norms started resulting in an increased number of mentally ill people in jail.
Man, I'm getting pretty far afield here, but I guess that I'm going into all of this because I'm leading up to something which is sort of controversial, and I don't want to make it sound like I'm just spouting this opinion off the top of my head without having thought about it.
I think we need to get back to more long term hospitalization or institutionalization or whatever you want to call it.
I know that there are plenty of mental health professionals and mental health advocates who will rail against the idea, and I'm not saying by any means that every person with a mental illness needs to be in an institution, but right now we're really not deinstitutionalizing the mentally ill population, anyway. We're just moving them from dedicated mental health facilities into criminal corrections facilities, and that's just not a good outcome.
Maybe we can build some kind of new, better facilities than were used previously, and I would really only propose the use of such facilities for individuals who have demonstrated an inability to function in mainstream society. But something really has to be done about the sort of revolving door that we've got going at our jails and prisons currently. Over and over again we see the same mentally ill defendants cycling in and out of jail.
The move toward deinstitutionalization was born out of a desire to respect personal autonomy and freedom and self determination, but in cases where patients have demonstrated an inability to function within normal society, I think that the desire to achieve these goals may actually be doing more harm than good.
One of the frustrating things is that many of these people respond fairly well to medication and treatment in the jail. We get them on meds for a few days or a week, and they clear up quite significantly. The hallucinations and much of the delusional thinking and compulsive behavior subsides (or at least becomes manageable), and as inmates many of these people seem to function pretty well. But then they get released and return to the streets (many of them are homeless, and many of the ones who do have homes tend to prefer wandering the streets as opposed to spending time at a residence) and within a short amount of time they've decompensated and fallen right back into the sort of behavior patterns that go them into trouble in the first place.
It's just a bad situation when a person's best, healthiest days are the ones spent in jail.

Anyway, I like my job and I think it's important and I like working on these kinds of legal issues (and I think that the intersection of criminal justice and mental health is a particularly important area right now given the issues and problems with both systems). At the same time I'm in the weird position of wishing that I had a fewer cases on my docket and a lot less to do (and in this case I'm not just saying that out of laziness ;-)). If the health care system were doing a better job in terms of providing help for sick people who aren't arrested or in jail, then we would likely be seeing a lot fewer of these people being arrested, and just about everyone would be in favor of that.

Well, I'm sorry if this was boring to some of you. This study just ties in to what I do in a pretty direct way, so I found it pretty interesting. You Adventurers should support funding for mental health services whenever possible. It's kind of an unusual issue for people who aren't directly affected by it (and the stigma of mental illness makes the whole topic sort of unpleasant for some people, it seems), but it's an important one and it affects an awful lot of people- probably more people in your life than you realize.

1 comment:

Anonymous said...

I agree with your comments about the move back to institutionalization/hospitalization/etc. It is sad, but much of the community is not ready to embrace (or even wanting to embrace) people with severe mental illness. I enjoyed your post on the subject.