All in the Family

Mental Illness and Caregiving Across the Generations

Prison or Treatment for People With Mental Illness?

America's jails have become our psychiatric facilities.

I gaze at my daughter's mugshot. The hazel eyes that used to light up a room stare blankly back at me. Her hair is cut ragged, most likely the result of a manic episode and access to a pair of scissors. Her orange jumpsuit partially covers the butterfly tattoo imprinted on her chest.

The charge: Failure to appear; possession of marijuana. She has an arrest number. 

This is not just a dumb kid who got caught with a little marijuana. This is a person with serious mental illness who has refused treatment for three years. She self-medicates with marijuana, methamphetamine, and alcohol. 

In fifth grade, my daughter was diagnosed with ADHD. As a high school junior, she was diagnosed with bipolar disorder; at 17, doctors added borderline personality disorder to her list of diagnosed conditions.

Treated, not only could she function, she was granted admission to one of our country's finest liberal arts colleges. I had high hopes for her. 

But my daughter, like many people with severe mental illness, also suffers from anosognosia—she has no idea how sick she is. Every doctor she saw told us that without treatment, she was not competent to make life decisions on her own. When she turned 18, my daughter stopped her treatments and left home. Nothing my husband or I did or said could make her change her mind. 

The mugshot is the first I've seen of her in three years.

I don't know whether to feel relief knowing she's no longer living on the streets doing hard drugs, anger for the mess that is her life, or fear of what will happen to her as she serves her 90-day sentence.

I do know that our incarceration system is not a great place for people with mental illness.

My daughter is one of 744,500 adults in jail.1 Jails are temporary holding facilities, typically run by a county sheriff. People in jail are either awaiting trial or serving short sentences. There are an additional 1,483,900 adults in our state and federal prisons.1 These facilities hold people convicted of crimes. Sentences are measured in months and years.

Research by Henry Steadman and his colleagues2 found that 14.5% of males and 31.0% of females in our jails suffer from serious mental illness.

America's jails have become our largest psychiatric facilities. According to The Treatment Advocacy Center,3 there are more severely mentally ill people in the Los Angeles County Jail, Chicago's Cook County Jail, or New York's Riker's Island Jail than there are in our psychiatric hospitals. And, there is not a single county in America in which the psychiatric facility serving that county has as many individuals suffering from severe psychiatric disorders as does the county jail.

In jail, my daughter will meet many people like her, but she's not likely to get the help she needs for her mental illness.

Because my daughter's jailers will rely on her report, it's not likely that they will even know she's been diagnosed with severe mental illnesses. Her anosognosia is so severe that, after she spent 10 days in an adolescent psychiatric hospital because her mania had her running away with a pervert she'd met on the Internet, all she told her psychiatrist was, "I'm having some trouble in my math class." It was up to me to report what had happened so the doctor could adjust her medications. But now that my daughter is over 18, the law says I cannot intervene. I can't talk with her jailers and I can't talk with her doctors. One of the things that would change if Congressman Tim Murphy’s H.R.3717 becomes law is that parents like me would be able to help their children.

But even if my daughter's jailers knew about her illnesses, she wouldn't get the medical care she needs. The jail she's in, like most jails, is underfunded and understaffed. They employ part-time doctors who are not likely to understand the complexities of the life-long mental illnesses that inmates have been suffering from. Although access to needed mental health services by inmates is protected under the Eighth Amendment, the reality is that jails do not have the required expertise and resources.4

Sixty years ago, people with severe mental illness would have been treated in hospitals. Now, with the failure of the deinstitutionalization movement, when people’s illnesses cause them to self-medicate and commit misdemeanors or minor felonies directly related to the symptoms of their untreated mental illnesses, they're dumped in jail. We're punishing the behaviors we once tried to treat. What kind of progress have we made?

At the end of her sentence, my daughter's mental illness will still be untreated, but she will have a criminal record.

Should we be punishing mental illness or treating it?

 

1. US Department of Justice. (2013). Correctional populations in the United States, 2012.
2. Steadman, H.J., Osher, F.C., Robbins, C.P., Case, B., & Samuels, S. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services 60:761-765.
3. Treatment Advocacy Center. (2009). Briefing paper: Jails and prisons.
4. The Council of State Governments Justice Center. (2012). Adults with behavioral health needs under correctional supervision: A shared framework for reducing recidivism and promoting recovery. 

 

Rachel Pruchno, Ph.D. is Endowed Chair and Professor of Medicine at Rowan University School of Osteopathic Medicine. Her memoir Surrounded by Madness comes out March 2014

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