If I suffered from a severe mental illness, Trieste would be my first-choice place to live. Patients in Trieste are regarded as valued citizens of the city, who need and deserve adequate services. They are treated in attractive and accessible, club-like community settings; with easy access to both psychosocial and medical care; with respect for their dignity and autonomy; and usually have paid jobs working for a large gardening coop run by the mental health system. There are no homeless and the thought of imprisoning people with mental illness would be shocking. 

The United States would be my last choice. We have criminalized mental health problems- a barbaric throwback to the dismal conditions before the enlightenment. Among peer countries, we have become the very worst place to have a severe mental illness. As D. J. Jaffe has documented in his wonderful new book, “Insane Consequences: How the Mental Health Industry Fails the Mentally Ill”, almost 400,000 US patients are currently prisoners; twice that number have previously been in jail and stand a good chance of rotating back; and about 200,000 are homeless. 

Prison conditions for the severely ill in the US are dangerous and disgusting beyond your imagination. And being homeless, always a severe challenge to human ingenuity, poses a daily threat of violence to those who are made most vulnerable by mental illness.

People with severe mental illness also die, on average, 20 years early- in large part because they are denied treatment, neglected and extruded from our society. 

The abuse and neglect of the mentally ill is a shameful stain on our nation. How did we get here? And how can we emulate Italy and the Nordic countries that provide humane care at lower cost?

D.J. Jaffe has written a brilliant, compassionate, and disturbing book that best explains the mess of our mental health non-system and how to solve it.

His "Insane Consequences" traces in intricate and fascinating detail how state governments deinstitionalized the severely ill by closing snake pit mental hospitals, only to reinstitionalize them again in completely inappropriate, even more degrading, and more expensive prison dungeons.

The crucial mistake was to discharge severely ill patients without providing anything approaching adequate community treatment and housing. Instead, community investments went to serve less severely ill people who never would have been hospitalized. The same is true today: hospitals are being closed and the most seriously ill are neglected while people with mild problems are often over-treated with medicines they don't need that may make them worse. 

Untreated patients with severe illness are a terrific burden on themselves, their families, and the community. Their psychotic symptoms and inability to care for themselves attract police attention. And because treatment facilities are almost non-existent, cops have no alternative but to bring them to jail, where they are vulnerable to attack, subject to solitary, and likely to decompensate further.

Community services for the most severely ill have been badly shortchanged because the states and federal government never developed a rational way of sharing costs for running them. Lack of overall planning and fragmented budgets led to attempts at cost shifting that left the severely ill out in the cold. 

The irresponsible default position was to privatize community treatment and expect it to mostly support itself through fees collected from patients. Many centers disappeared and those that survived did so by cherry picking the most profitable patients and neglecting the severely ill. 

For many years, Jaffe has been one of the most passionate and effective advocates for the severely ill. He has exposed the great waste in government funding devoted to frill programs geared to the worried well, while neglecting the desperate needs of the severely ill. His efforts have helped secure the recent passage of legislation that will promote a more rational allocation of resources and improved community care and housing for the people who need it most. His book proposes many additional solutions to our mental health crisis that would greatly improve the well-being of our mentally ill citizens and reduce the incivility of our society. 

We must deinstitionalize our prisons and treat our mentally ill as people. Snake pit hospitals made them seem sicker than they were and so do street neglect and prison confinement. We must bring out the best, not the worst, in the severely ill. 

And we should ensure that caring for them brings out the best, not exhibits the worst, in our society. Serving the mentally ill must be a public responsibility. Privatization has been a national disaster that needs immediate correction. A single visit to a prison would enlighten even the dumbest politician to the fact that our current non-system is a barbaric failure and a tragic waste of money.

Thanks to D.J. Jaffe for "Insane Consequences". It is a must read for all mental health professionals, patients, families, and politicians. Our system is badly broken and needs an immediate and thorough fixing. 

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