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.
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.