We’re Still Locking Up the Mentally Ill

When the only prescription is jail time.

Sady Doyle June 8, 2018

Illustration by Erin McCluskey

A few year back, I went to a new nurse prac­ti­tion­er for a med­ica­tion adjust­ment for my bipo­lar II dis­or­der. I went through an intake ques­tion­naire. I list­ed my stres­sors: I was under extra pres­sure at work, I was plan­ning my wed­ding, and my fiancé and I were try­ing to start a fam­i­ly. The NP nod­ded; she lis­tened.” Then she pre­scribed me — a woman who’d just said she was try­ing to con­ceive — a med­ica­tion linked to birth defects.

Mentally ill people are arrested for drug use (because they’re self medicating) or causing a public disturbance (because they’re manic or delusional).

Bipo­lar dis­or­der and preg­nan­cy are a tricky mix. Most med­ica­tions have side effects, and going off med­ica­tion is dan­ger­ous in its own right; it’s up to each woman to choose among the risks. But I wasn’t giv­en that choice. The nurse prac­ti­tion­er didn’t tell me the medication’s poten­tial effects on a preg­nan­cy; she didn’t dis­cuss alter­na­tives. I didn’t real­ize what she’d done until I Googled the med­ica­tion a few weeks later.

There’s a long his­to­ry of eugeni­cist think­ing around men­tal ill­ness. Before the 1970s, it was com­mon for peo­ple who had been insti­tu­tion­al­ized to be ster­il­ized. In 1995, Kay Red­field Jami­son wrote that she left a doctor’s appoint­ment in tears because he had told her she’d be an inad­e­quate moth­er” due to her man­ic-depres­sive ill­ness.” In 2018, doc­tors don’t say things like that aloud. They just don’t con­sid­er your poten­tial preg­nan­cy impor­tant enough to take into account when mak­ing decisions.

So, sure: The inci­dent could have been pure incom­pe­tence, a brain fart, bad com­mu­ni­ca­tion. But I don’t think so. I think she didn’t tell me because she didn’t think a bipo­lar woman was capa­ble of mak­ing an intel­li­gent deci­sion. I think the idea that some­one with my ill­ness had the poten­tial to lead a pro­duc­tive, hap­py, nor­mal life — which includ­ed preg­nan­cy — or that I could be use­ful­ly con­sult­ed about my own care sim­ply didn’t occur to her. The rea­son­ing could have been sub­con­scious; hell, it prob­a­bly was. But it taught me a hard les­son: Even peo­ple who take it upon them­selves to help” the men­tal­ly ill some­times don’t think we should have a voice in our own care.

This les­son came to mind often when read­ing Insane: America’s Crim­i­nal Treat­ment of Men­tal Ill­ness, Alisa Roth’s explo­ration of the dis­pro­por­tion­ate incar­cer­a­tion of men­tal­ly ill peo­ple in Amer­i­ca. Unfor­tu­nate­ly, it did not always come to mind for rea­sons that the author intend­ed. Roth is pas­sion­ate and her book is har­row­ing on the top­ic of mass incar­cer­a­tion, but her under­stand­ing of the lived expe­ri­ence of men­tal ill­ness falls frus­trat­ing­ly short. 

Roth’s book does deal with a gen­uine cri­sis. Accord­ing to the Nation­al Alliance on Men­tal Ill­ness, near­ly 15 per­cent of men and 30 per­cent of women in pris­ons have a men­tal ill­ness. Pris­ons and jails have become America’s means of ware­hous­ing men­tal­ly ill peo­ple who are too poor to receive med­ical care. To call the care they receive in prison inad­e­quate” is laugh­ably opti­mistic. Roth writes that pris­ons and jails are psy­choto­genic,” mean­ing that they active­ly aggra­vate and even cause psy­chosis; peo­ple come out sick­er than they went in. 

That’s assum­ing they come out. There are many noto­ri­ous sto­ries of men­tal­ly ill peo­ple killed by police or prison guards. Roth shares one sto­ry in which a bipo­lar man ate indus­tri­al cleanser while scrub­bing his cell and was denied med­ical care until his innards melt­ed. In 2015 and 2016, she notes, one in four [fatal] police shoot­ings was of a per­son with men­tal ill­ness.” In more local­ized stud­ies, that num­ber ris­es — some­times to 100 per­cent. “[In] the first half of 2017,” Roth writes, police in San Jose, Cal­i­for­nia, shot six peo­ple, four fatal­ly. All had a men­tal ill­ness.”

Roth has an eye for the grue­some anec­dote: the man who ate cleanser, or anoth­er bipo­lar man who was aban­doned in his cell dur­ing a man­ic episode until he pulled his own eye­ball out. Yet, when it comes to the men­tal­ly ill — who are most famous to the gen­er­al pub­lic as vil­lains in hor­ror movies — scary” and bloody” are not always the best way to make the point. 

Roth is sim­i­lar­ly fond of the­atri­cal cra­zies; her exam­ple of unjust sen­tenc­ing is James Holmes, who got 12 life sen­tences for killing 12 peo­ple. Her exam­ple of prison sui­cide is a man who killed his own moth­er and lat­er killed him­self because he couldn’t for­get her dying screams, a form of remorse that (one hopes) might also affect neu­rotyp­i­cal mom-killers. She notes that men­tal­ly ill peo­ple are more like­ly to be the vic­tims of vio­lence than its per­pe­tra­tors, but she’s evi­dent­ly fas­ci­nat­ed by the spec­tac­u­lar vio­lence of these cases. 

The prob­lem is that these men aren’t par­tic­u­lar­ly rep­re­sen­ta­tive. As a court psy­chi­a­trist quot­ed by Roth notes, men­tal­ly ill peo­ple are often charged with [minor] crimes, such as pub­lic drunk­en­ness.” Police offi­cers, the psy­chi­a­trist explains, regard arrest and book­ing into jail as a more reli­able way [than hos­pi­tal­iza­tion] of secur­ing invol­un­tary deten­tion of men­tal­ly dis­or­dered persons.”

That psy­chi­a­trist was writ­ing in 1972, but things have not changed much. A 2002 report by The Sen­tenc­ing Project found that “[the] revolv­ing door’ between jail and the street is pro­pelled large­ly by untreat­ed men­tal ill­ness and co-occur­ring sub­stance abuse dis­or­ders among indi­vid­u­als who have com­mit­ted rel­a­tive­ly minor crimes.” Men­tal­ly ill peo­ple are arrest­ed for drug use (because they’re self-med­icat­ing) or loi­ter­ing (because they’re home­less) or caus­ing a pub­lic dis­tur­bance (because they’re man­ic or delu­sion­al), not because they’re a threat, but because invol­un­tary deten­tion” is regard­ed as a good in itself — that is, they are arrest­ed, impris­oned and some­times killed for the crime of being men­tal­ly ill.

Roth does nod to this oth­er real­i­ty. But aside from a line or two about stig­ma,” she fails to grap­ple with the idea that men­tal­ly ill peo­ple are dis­pro­por­tion­ate­ly thrown in prison and treat­ed espe­cial­ly bad­ly there because of prej­u­dice. She gets close to the point sev­er­al times with­out ful­ly grasp­ing it, as when she writes that Tho­razine, the first wide­ly pre­scribed anti-psy­chot­ic in state hos­pi­tals, had been used else­where as an insec­ti­cide and seemed to cause per­ma­nent brain dam­age,” or when she notes that the move­ment against insti­tu­tion­al­iza­tion was sparked by cas­es like one woman whose hus­band had her com­mit­ted for refus­ing to be an obe­di­ent wife [and] end­ed up spend­ing three years in an Illi­nois hos­pi­tal.” (This was not a rar­i­ty, but a wide­spread form of spousal abuse.)

No lie: In the para­graph direct­ly after that Illi­nois exam­ple, Roth rumi­nates that many fam­i­ly mem­bers [of patients] I have talked to … believe the laws have gone too far in the direc­tion of patients’ rights,” and argues that the bar­ri­ers to invol­un­tary com­mit­ment [are] one of the rea­sons for the increased crim­i­nal­iza­tion of men­tal illness.”

Frankly, some­one who believes things can go too far in the direc­tion of rights for men­tal­ly ill patients should not be writ­ing about men­tal ill­ness. Invol­un­tary com­mit­ment is not a solu­tion to the mass incar­cer­a­tion of the men­tal­ly ill; it is anoth­er, slight­ly dif­fer­ent form of incarceration. 

We don’t need a kinder, gen­tler ware­house. We need acces­si­ble, afford­able, com­mu­ni­ty-based out­pa­tient care; we need sup­port­ive hous­ing and insur­ance cov­er­age for men­tal health treat­ment; we need cul­tur­al des­tigma­ti­za­tion; we need edu­ca­tion, train­ing and incen­tive pro­grams to end the crit­i­cal short­age of men­tal health pro­fes­sion­als; we need com­mon-sense pre­ven­ta­tive mea­sures that can treat someone’s men­tal ill­ness before they’re ren­dered des­ti­tute and arrest­ed or shot by the police. Dein­sti­tu­tion­al­iza­tion has been one of the sin­gle most fierce­ly fought caus­es for dis­abil­i­ty advo­cates in the past cen­tu­ry, yet Roth’s sources do not appear to include many men­tal­ly ill dis­abil­i­ty advo­cates. She includes the men­tal­ly ill as vic­tims and cau­tion­ary tales, but sel­dom as experts on their own care.

The crim­i­nal­iza­tion of men­tal ill­ness in this coun­try is a cri­sis. If a mid­dle-class white woman can be casu­al­ly endan­gered by her doc­tor at an out­pa­tient appoint­ment, then a work­ing-class woman of col­or with the same ill­ness can be (will be) impris­oned, abused, trau­ma­tized and killed. 

This cri­sis is due to the atroc­i­ties of the prison sys­tem, which Roth elo­quent­ly details. But it is also due to the same casu­al con­tempt that men­tal­ly ill peo­ple meet every­where. It’s not uncom­mon for that con­tempt to work its way into left pol­i­tics: Wit­ness the oth­er­wise exem­plary orga­niz­ing of the Park­land teens, who have sug­gest­ed weak­en­ing pri­va­cy laws for the men­tal­ly ill as a gun con­trol mea­sure, despite the fact that there’s no sta­tis­ti­cal link between gun vio­lence and men­tal illness. 

Roth tries, but ulti­mate­ly fails to counter this fatal fal­la­cy: That there are peo­ple with chron­ic phys­i­cal ill­ness­es who deserve health­care that empow­ers them to live full lives, and then there are the men­tal­ly ill,” whom you can lock up some­where and med­icate with insec­ti­cides until they qui­et down. Until we deal with it, we’re unlike­ly to see the prob­lem with a crim­i­nal jus­tice sys­tem that spe­cial­izes in lock­ing up men­tal­ly ill peo­ple. Roth’s book gets us halfway there; I wish she’d done the rest of the work. 

Sady Doyle is an In These Times con­tribut­ing writer. She is the author of Train­wreck: The Women We Love to Hate, Mock, and Fear… and Why (Melville House, 2016) and was the founder of the blog Tiger Beat­down. You can fol­low her on Twit­ter at @sadydoyle.
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