By Michelle Lugalia-Hollon, Contributing Editor, Global Health
In an unprecedented national call-to-action to lower the number of people with mental illness in the jails, the Council of State Governments Justice Center (CSG) and the National Association of Counties (NaCo) convened leaders in behavioral health and criminal justice at the end of last year. In the United States, where dealing with mentally ill citizens has caused much hand wringing and little sustainable progress over the last few centuries, this is a big deal.
The mentally ill have cycled through various institutions, from asylums to nursing homes, which have all assumed and lost the responsibility for treating them depending on the reform of the day. Though evidence-based solutions have been well researched, implemented and documented, years of effort to adequately address severe mental illness have failed to take root primarily due to inadequate financial support for well-meaning reforms. Across the nation, as best-practices have continued to be gutted, these primarily poor and under-resourced individuals have lost access to the mental health and social services that can keep them healthy, housed and employed. Without access to these vital services mentally ill citizens are left to survive in communities where their unmanaged mental illnesses drive their repeated involvement in illegal behaviors that lead to their arrests. This criminalization of mental illness has led to a disproportionate number of these citizens detained in jails and prisons. Consequently, prisons and jails have become the largest and most utilized mental health institutions across the United States.
How did we get here?
In the 1700s the country established Public Hospitals for Persons of Insane and Disordered Minds. These spaces were horrible places for any human being to live in, and back then people thought that mental illness could not be treated, only managed. In this era, states concluded that mental problems were hereditary and some even enacted eugenics laws to sterilize mentally ill people. In the 1840s, a school teacher who witnessed these terrible conditions in asylums successfully lobbied for the establishment of psychiatric hospitals with the belief that mental illness could be cured. These hospitals did not turn out to be healthy institutions either, but at the time the powers that be, including the medical community, didn’t have the benefit of research to help them understand the various types of mental illness and subsequently devise effective solutions.
The 1930s brought “advancements” in science with the first lobotomy performed in 1936, the introduction of electroshock therapy in 1938, and the development of new medicine to treat psychoses shortly after. In 1946, President Truman signed the National Mental Health Act, establishing the National Institute of Mental Health that would focus on understanding neuropsychiatric illnesses. By 1955 there were 560,000 mentally ill people in state psychiatric hospitals with abysmal conditions and they were draining state budgets. Something had to be done.
The 1960s offered some hope, but unfortunately inadequate support for proven alternatives doomed the intended reforms in practice. In 1961, a Joint Commission released Action for Mental Health, which outlined sound strategies for deinstitutionalization. In 1963, in response to this report as well as concerns and pressure over the morbid conditions of state mental hospitals and the civil rights of the occupants, President Kennedy signed the Community Mental Health Act. This fueled the national deinstitutionalization movement and established the community mental health centers program. Mentally ill folks were released into the community, where they were supposed to live independently with the support of comprehensive social and mental health services.
The passing of Medicaid in 1965 further incentivized this exodus, as state mental health hospitals could no longer receive reimbursement for keeping patients. Those with severe mental illness were placed in long-term care institutions like nursing homes and those who were somewhat functional were placed in group homes, assisted living facilities, board-and-care homes. From 1955 to 1977 state hospital use declined by 30%. Lamentably, the Vietnam War and sordid economic realities meant that these programs and facilities were not adequately funded.
As a result – though laws were changing to protect mentally ill citizens – the absence of support for community-based alternatives led to unintended consequences. For example, under Governor Ronald Reagan, California passed the Lanterman-Petris-Short Act in 1967, which meant that mentally ill people could not be involuntarily hospitalized by the judicial system unless they posed a proven, serious threat to themselves or others. While this law appropriately protected the civil rights of mentally ill residents, doing so without granting them access to adequately supported community-mental health services led to a series of disastrous trends. Within a year, the number of mentally ill people in California’s jails and prisons doubled, homelessness increased and homicides involving mentally ill residents soared as well. This trend was replicated across the nation as deinstitutionalization without adequate support continued.
In 1980, President Carter’s Commission on Mental Health released recommendations for further deinstitutionalization and worked to restructure Kennedy’s mental health center program to get better outcomes, but again, funding was limited, so things only got worse. The 1980s wrought more terrible outcomes for mentally ill citizens but this time their plight was finally gaining national attention thanks to high profile investigations, news coverage and notorious crimes, including the shootings of John Lennon and President Reagan by mentally ill citizens.
Moving mentally ill people from horrid state hospitals into the community was a sound ideal, but inadequate and inconsistent support for community services led to their institutional abuse, deaths, homelessness and increasingly, their incarceration. Cue President Reagan – are you keeping track of the presidents? – who in 1981 acted on his “small government philosophy” and repealed Carter’s community health systems act, ending federal service delivery to this population. This was not good. Overall, federal mental health spending decreased by 30% and an additional 11% in 1985. Public housing was cut too and homelessness among the mentally ill surged. By the late 1980s jail and prisons were reporting unprecedented numbers of detainees with psychotic disorders, a trend that has persistently increased till today.
This is, in short, a brief history of how we got into the hot mess we are in today. Across the nation, mental health budgets have been slashed consistently over the past 20 years, even as research and practice have demonstrated that doing so only results in the same people receiving those services in the most expensive and inappropriate settings, emergency rooms, jails and prisons. In 2004, there were three times as many seriously mentally ill people in jails and prisons than in hospitals. From 2009 to 2012, states cut $4.35 billion in mental health spending, further reducing the services available to this population. Currently across the nation, in cities like Chicago, approximately a third of detainees in the county jail have a diagnosable mental illness on any given day.
So color me cautiously optimistic to hear that state, county and city leaders finally get it. Through the NaCo and CSG call to action, launching Spring 2015, they are committing to “concrete, multi-step planning and implementation processes that achieve measurable results”. Mounting expenses and sagging budgets have nudged government leaders into this conversation and major cities like New York and San Antonio are demonstrating the way forward. Mayor DeBlasio’s administration just released a multi-sector strategic plan to address mental illness in their jails. Bexar County, San Antonio established The Restoration Center in 2007 and trained police to appropriately intervene with and engage mentally ill offenders and divert them to the center instead of taking them to the jail. This has drastically reduced the county’s jail population, now maintaining 1,000 empty beds, sustaining an astounding 6% recidivism rate and saving the county $10 million a year.
The tide is changing and this fantastic news means that the same parties that have historically voted to reduce mental health funding have finally realized that they do so at their own peril. As Senator Al Franken said at the call to action meeting: “This is a moral issue and an economics issue. When we use our jails to warehouse people with mental illnesses, we burden the judicial system, the public health system, our law enforcement offices, and the taxpayers. In confronting this problem, we know that some of the most innovative solutions come from our local communities. It’s our job to make sure they’re properly supported.”
Let’s agitate to make sure that they get it right this time.
Law Enforcement, Health Advocates, and Members of Congress Push to Reduce the Number of People with Mental Illness in Jails. 12/16/2014. Center for State Governments – Justice Center.
TIMELINE: Deinstitutionalization and its consequences. Mother Jones, 4/29/2013.
Ronald Reagan’s Shameful Legacy: Violence, the homeless, mental illness. Torrey, E. Fuller. Salon Magazine, 9/29/2013.
Learning from History: Deinstitutionalization of People with Mental Illness as Precursor to Long –Term Care. The Henry J. Kaiser Family Foundation, 2007.