Saving Normal

Mental health and what is normal.

Sexual Abuse Of Psychiatric Patients In Prisons

A national scandal

Sexual abuse is shockingly common in the US prison system. A recent survey conducted by the Bureau of Justice Statistics concluded that about 200,000 prisoners are sexually abused each year.

Most of the abused prisoners are misplaced psychiatric patients who make especially vulnerable targets because they are less able to defend themselves and to be believed if they report infractions.

Although prison is clearly not the right place for psychiatric patients, almost a million are behind bars for crimes that could have been avoided if there were proper community treatment. Because there isn't, prison has become the default disposition for those patients who can't make it on their own. They usually get incarcerated for non-violent nuisance crimes that result from neglect, not evil intent.

The rate of overall institutionalisation for psychiatric patients has remained fairly constant for the past eighty years, but a trans-institutionalization has shifted them from hospitals to prisons. We have closed almost a million hospital beds, but have added the same number of cells for psychiatric patients.

It wasn't supposed to be this way. The dollars saved by closing beds were supposed to follow the patients, supporting them in community settings where they would have a richer and freer life. Instead, the states welched on their obligations to the mentally ill. Attempted to trim their budgets, and the states have paradoxically and irrationally spent the same dollars building inappropriate prison cells.

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The obvious solution is to decriminalize mental illness, to fund adequate services for the mentally ill so that they don't wind up in prison. This is not rocket science. The rest of the developed world got this message two hundred years ago. The US lags far behind European countries and has been getting progressively worse as its always inadequate mental health system has been further dismantled by budget cuts.

These rape survey data also contribute to the discussion of whether forced psychiatric treatment is ever justified. Eleanor Longden and I recently wrote a blog agreeing that forced psychiatric treatment can on rare occasions be appropriate when there is otherwise the threat of clear and present danger to the patient or another. Eleanor's statement showed her great common sense and understanding since she had herself been the victim of considerable inappropriate psychiatric coercion.

Some of the responses to the blog were less enlightened by common sense and less informed about the risks prisons now pose to psychiatric patients. Although most coercion of psychiatric patients now occurs in prisons, not hospitals, some respondents argued that prison was really preferable to forced psychiatric treatment—it provided more protection of civil rights and was more justified because a crime had already been committed.

I am convinced of the sincerity of these advocates for the mentally ill, but am equally convinced they are now fighting the wrong fight. The risks and priorities have shifted—fifty years ago a million patients languished in snake pit hospitals, now they languish in much more dangerous and degrading snake pit prisons.

Psychiatric patients do not do well in negotiating the perils and routines of prison life. Too often they wind up in solitary confinement, which can drive anyone crazy. To get a full appreciation of depths of degradation of prison life for psychiatric patients you have to see and smell the rows of cells where extensive excrement smearing has become a last resort of desperation. And, as just documented by the prison system itself, psychiatruc patients are prime targets for sexual (and probably other forms) of violence.

Everyone interested in the welfare of psychiatric patients should join in the effort to end their barbarous imprisonment. The battle against inappropriate psychiatric coercion has largely been won; the much more urgent battle again inappropriate prison coercion needs all the help it can get.

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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