New Bedlam: Jails--Not Psychiatric Hospitals--Now Care for the Indigent Mentally Ill.

When Timothy Williams arrived in late 1997 at the Alexandria Adult Detention Center (AADC) in Alexandria, Virginia, he'd just come off a spree of nine burglaries, mostly stealing VCRs and other home electronics to support his crack habit. The thirty-eight-year-old Alexandria native is dually cursed with a drug addiction and paranoid schizophrenia, and during his last term in a Virginia penitentiary had tried to commit suicide by cutting his arms 200 times with a razor. He was off his anti-psychotic medication.

"When I'm on medication," he says, "I'm a nice guy to be with. When I'm off it, I'm a damn devil."

Fortunately, this time Williams was jailed at the AADC, a federal demonstration project for treating the mentally ill in jail. He says counselors there patiently persuaded him to get back on his anti-psychotic medication. "If they hadn't come to me, I'd have been dead now by suicide," says Williams.

Sadly, many U.S. jails are nowhere near as equipped to handle the mentally ill as the AADC, and newspapers are full of suicides of inmates with a history of mental illness. A 1997 Justice Department investigation of the Men's Central Jail in Los Angeles included a report of an inmate who, despite a known history of mental illness and suicide attempts, was not being housed in a suicide observation cell. Repeated requests for anti-psychotic medication by the inmate and a social worker were ignored, and he was soon found hanging in his cell, "cold to the touch."

The report describing this incident reads like a series of all-too-truthful apologues illustrating how detainees with mental illnesses slip through the cracks, wither, and die behind bars. With incarceration rates rising yearly, more and more people with schizophrenia, severe depression, and manic-depressive disorder (the so-called severe mental illnesses) are serving time in jails, which have become the largest de facto providers of mental health services in many cities around the country.

According to a 1997 American Jails website article, "Jails and Prisons: The Numbers Say They Are More Different Than Generally Assumed," by corrections expert Michael O'Toole, between 600,000 and one million jail admissions each year are people who suffer from severe mental illness, and studies of men in large urban jails have shown rates of schizophrenia, major depression, and manic-depressive disorder to be two to three times higher than in the general population.

The jailed mentally ill are usually low-income people with no money, friends, or family to bail them out. About half don't realize they are ill and don't understand why they need medication. People with mental illnesses end up in custody because public mental health centers have, for a variety of reasons, been unwilling or unable to help them.

Without the medication they need to keep their illness in check, they sometimes lapse into psychosis and behave in bizarre ways that attract the attention of police. Because police often find the local mental health care system unresponsive, they resort to arresting people with mental disorders. Jailed on misdemeanor charges and released within a year, the indigent mentally ill then forage for services as best they can until, unmedicated, they relapse into psychosis.

Some commit a small offense that again lands them in jail, while others are capable of horrific crimes. Earlier this year, thirty-two-year-old Kendra Webdale was pushed to her death under a Manhattan subway train by a paranoid schizophrenic. Another paranoid schizophrenic, Russell E. Weston Jr., was charged last year with the shooting deaths of two police officers at the U.S. Capitol.

In too many states, a ping-pong game has developed between jails and community mental health centers in which the indigent mentally ill are swatted back and forth between institutions. This situation benefits no one, least of all the mentally ill.

Most jails were not designed to be mental hospitals, and most jailers were not trained to care for psychotics. Budgetary constraints, antiquated facilities, and the short sentences imposed on misdemeanants compound the difficulties of mental health treatment in jails.

Finally, the ping-pong game is expensive and not in the best interests of public safety. Better community treatment for the indigent mentally ill would result in fewer costly psychiatric hospitalizations, reduced jail expenses and more space for serious criminals, and more street time for police freed from responding to mental health emergencies. According to a 1996 Pacific Research Institute for Public Policy report, California, for example, now spends between $1.2 billion and $1.8 billion annually on the mentally ill in its criminal justice system. Comprehensive community treatment programs might reduce these expenses and help turn some former inmates into productive members of society.

An unhappy truth revealed by a study of nineteenth-century mental health reform in the United States is that the central issue confronting activists of the 1840s is the same one confronting activists today: removing the mentally ill from jails. It was widespread practice in eighteenth-century America to house insane paupers, as they were then called, in jails and poorhouses.

But the 1820s and 1830s brought an era of heightened social consciousness, spearheaded by Unitarian and Quaker reformers. In 1842, Dorothea Dix, a former Boston schoolteacher steeped in Unitarian theology, wrote Memorial to the Legislature of Massachusetts, a thirty-two-page text vividly describing the plight of the impoverished mentally ill. Dix considered herself an instrument of divine will and imbued the text with evangelical fervor. Confining the criminal and the insane in the same building, she wrote, was "subversive of the good order and discipline which should be observed in every well-regulated prison."

While campaigning to build a mental institution in New Jersey, Dix wrote that, while jails were built "to detain criminals, bad persons, who willingly and willfully [transgress] the civil and social laws," the mentally ill were innocents, guilty of nothing but "laboring under disease." Jailing them, she wrote, made as much sense as jailing someone for contracting tuberculosis.

In the remaining forty-five years of her life, Dix would badger and shame state legislatures around the country into opening thirty psychiatric hospitals for the indigent. By 1880, only 397 of 91,959 mentally ill persons--0.4 percent!--were housed in jails. Dix's humanitarian appeals were clearly effective.

But by 1945, the hospitals Dix had lobbied for were in a shambles, the subject of newspaper and magazine exposes. A Life magazine article reported that many facilities had been allowed "to degenerate into little more than concentration camps on the Belsen pattern." Activists sought to reform conditions, but in 1961 a number of intellectuals published attacks that provided ammunition for those who would shut the hospitals permanently. In Asylums, sociologist Erving Goffman stressed that mental hospitals had a custodial function as residences for people society considered troublesome that was inconsistent with their medical mission. Because their confinement was involuntary, the mentally ill were often resentful and uncooperative patients.

In The Myth of Mental Illness, psychologist Thomas Szasz argued that mental disorders did not exist but were convenient labels used to describe behavior that society didn't like. Four years later, French thinker Michel Foucault, in Madness and Civilization, would lambaste the mental hospital as a coercive form of social control. As the decade progressed, this intellectual critique soon became yoked to the broader social movements of the 1960s; the mentally ill were viewed as an oppressed group in need of liberation.

In the next decade, a number of factors conspired to restrict the use of public mental hospitals. Breakthroughs in the treatment of people with mental illnesses called into question the necessity of long-term confinement in hospitals. The first anti-psychotic drugs, available since the mid-1950s, were becoming widely available and appeared to control some of the symptoms of severe mental illness. Mental hospitals, moreover, were a drain on state budgets and carried the stigma of abuse and neglect.

Federal social welfare programs enacted in the 1960s also hastened deinstitutionalization. Low-income people with mental illnesses became eligible for such programs as Medicare, Medicaid, Supplemental Security Income, Social Security Disability Insurance, and subsidized housing once released from state hospitals. This provided great incentive for states to shut down their hospitals, sending ex-patients in need of intensive care to nursing homes and other facilities where the federal government would pick up the tab. According to the 1997 book Out of the Shadows by E. Fuller Torrey--a Washington, D.C.-based research psychiatrist who has written extensively on deinstitutionalization--between 1955 and 1994, the number of patients confined in state psychiatric hospitals dropped from 558,922 to 72,000.

The 1960s also witnessed the tightening of state laws regulating involuntary hospitalization. Whereas in the past, psychiatrists had considerable latitude in deciding who to hospitalize and medicate against their will, now they could only do so if patients were dangerous to themselves or others.

By the late 1970s, every state had changed existing laws or enacted new ones to restrict psychiatric hospitalization to this dangerousness criterion. This ensured that there would be a vastly reduced constituency for mental hospitals in the future.

Indigents who had previously been confined in hospitals were now meant to live in the community and receive medication and counseling at public clinics called Community Mental Health Centers, which were built and staffed with $3 billion in federal money. By the early 1970s, researchers were noticing that some former patients were slipping through cracks in the community mental health care system, ending up homeless, psychotic, and arrested by police.

In 1972, Marc Abramson, a California psychiatrist, published a prophetic article in the Journal of Hospital and Community Psychiatry in which he coined the term criminalization of the mentally ill to describe the increasing numbers of people with mental disorders who were being arrested. He predicted that, as more people with mental disorders were released into the community, "there will be an increase in pressure for use of the criminal justice system to reinstitutionalize them."

A 1984 study by Linda A. Teplin of Northwestern University Medical School showed that suspects exhibiting signs of mental illness were 20 percent more likely to be arrested than those who appeared not to be mentally ill. The next year, mental health researcher John R. Belcher's study of 132 patients discharged from Ohio's Columbus State Hospital in 1985 showed that 32 percent had been arrested and jailed within six months of their release. Many researchers and mental health professionals were now seeing criminalization as one of deinstitutionalization's many malign and unintended consequences.

Of all the reasons why community mental health centers have failed people with serious mental illness, the most damning is that they have given preferential treatment to people with minor coping problems--the so-called worried well. Though the centers were established to care for people with serious mental illnesses as the state psychiatric hospitals closed, the federal government failed to mandate any relationship between the hospitals and the new mental health facilities. When the hospitals closed, the mentally ill were often not referred to the community centers, which in their absence began to treat people with life-adjustment problems.

Torrey characterizes the community centers' neglect of the indigent mentally ill as an abdication of their psychiatric responsibility:

   If you have public psychiatric services, you have to decide what your
   priorities are and how those services are going to be allocated. If a woman
   whose teenage daughter is no longer speaking to her has the same right of
   access as people with brain diseases who are hearing voices ... society is
   going to pay a certain price for that decision. People with voices in their
   head have to get priority.

Community mental health providers are also ill-equipped to deal with the constellation of problems often accompanying the indigent mentally ill. "The problem is that most of these people have long-term, serious substance-abuse problems," says Bonita M. Vesey, a mental health policy researcher. "Sometimes their crimes are violent--30 percent are convicted of violent crimes--and they're homeless, resistant to treatment. These are probably the most difficult people to engage and treat."

Teplin, now director of the psycho-legal studies program at Northwestern University Medical School, says that few states have established agencies to treat both mental illness and drug and alcohol addiction, and that people with both disorders are often seen as too disruptive to be treated by either mental health or detox clinics. "We train counselors as if people were pure types," she says, "and we fund programs as if people were pure types. You're either this or that. There are fewer pure types than we would like. Pure types are easier to treat."

Funding issues also play a part in the decision of clinics to get rid of the mentally ill as soon as possible, according to Torrey:

   If I'm running a public health center, my job is not to spend any more
   money than I have for housing and board or placement for mentally ill
   people. So if there are a thousand mentally ill folks out there on any
   given day, and 150 of them are in jail, then they are not my
   responsibility. They are going to cost the Department of Corrections money,
   but they are not going to cost me money.

The same attitude, he says, is prevalent in the jails:

   If I'm running a jail system ... and if 16 percent of my cells are loaded
   up with mentally ill people, that's coming out of my budget and I'm going
   to do whatever I can to get these folks back over to the public mental
   health services as quickly as I can.

Torrey blames the mental health community for favoring budgetary shell games to treatment:

   Mental health professionals in large number are contributing to this kind
   of sloughing off of responsibility back and forth. It's almost like it's
   part of our training. We have a greater ability to rationalize why [the
   mentally ill are] not our responsibility than the average man in the
   street.

Lacking treatment programs in the community, mentally ill ex-offenders are likely to stop taking their medicine. Timothy Williams, the inmate at the AADC, says he stops taking his medication when he gets frustrated. This happens not in jail or prison but on the street, where he is particularly vulnerable: his parents are dead and he never learned to read or write. Friends in his neighborhood are bad influences, he says, because they tell him he doesn't need the medication.

He adds that, in the past, he didn't want to associate himself with the mentally ill--a group often portrayed on television as homicidal maniacs. Only after being medicated is he able to understand that he has committed crimes. "By then I'm in jail and it's too late," he says.

Police encounters with the mentally ill can be frustrating and time consuming. Police often must decide whether to arrest, seek out a community mental health center during its hours of operation, or find a hospital emergency room. The latter two options may be unavailable because of limited space for police referrals, restrictive admission criteria, and a general reluctance to take on problem cases.

According to Bonita Vesey, police can be "tied up for six to eight hours trying to get somebody hospitalized. Most emergency rooms require officers to sit with a person until they're seen by a physician." Lacking any options, police generally arrest the mentally ill, usually on misdemeanor charges.

A 1991 telephone survey of 1,401 families who belong to the National Alliance for the Mentally Ill revealed that 40 percent of the disordered people in this advocacy group had been arrested at some point in their lives. The rate of arrest among the severely disordered who use public mental health facilities is probably higher. Two University of Pennsylvania researchers recently predicted that, if current rates of incarceration continue, a majority of the public mental health clientele will have experienced criminal detention.

Ironically, many mentally ill people appear dangerous enough to be arrested but not dangerous enough to be hospitalized. While laws limiting involuntary hospitalization to the dangerousness criterion have been applauded by some as a victory for civil liberties, others have attacked them for denying treatment to all but the sickest.

Police are arresting and courts are jailing disordered people in jurisdictions where it's nearly impossible to get an involuntary commitment, says Torrey. "Being a danger to yourself or others means you either have to be trying to kill yourself in front of your psychiatrist or be trying to kill your psychiatrist."

But there are now proposals to change state commitment laws. Following Kendra Webdale's death earlier this year, New York State Attorney General Eliot Spitzer proposed a bill allowing family members and caregivers--with the support of a psychiatrist--to obtain a court order to ensure that mentally ill people take their medication. Should a mentally ill person refuse prescribed medication, violating the court order, they could then be forcibly hospitalized. But for states with stringent involuntary commitment laws or poor community care, jails remain an attractive option for police handling mentally ill offenders.

Vesey, who serves as a consultant to jails seeking to improve mental health services, says she sometimes worries she is inadvertently encouraging incarceration. "The problem," she says, "is that, when the services provided in the jails are superior to those in the community, judges and police know that at least when they can get people in jail they will receive treatment."

How much treatment is available in jail? That depends on the jurisdiction. Cities like Alexandria run model programs, while others ignore legal mandates to provide psychiatric checkups. Funding appears to be the issue. "It's expensive," says Teplin. "Not only do jails have to retain a psychiatrist ... but once they find someone who has a serious disorder, they have to make arrangements to treat them. It's much easier not to do it and not to know whom you have."

With jails in the country's twenty-five largest jurisdictions at 96 percent capacity, they are overburdened, underfunded, and ill-equipped to become treatment facilities for large numbers of mentally ill. "The states have forgotten that it's their responsibility to ensure that there are adequate resources for local criminal justice and mental health agencies," says Stephen J. Ingley, executive director of the American Jail Association, a nonprofit training and support group. "They've abdicated that responsibility."

Ingley says he hears complaints from jail directors "all the time" about how they are incarcerating increasing numbers of mentally ill. "It comes down to another unfunded mandate," he says. "Jails are forced to care for these individuals.... The frustration is that these people keep coming back and back and back, because jails don't have the resources to provide them with the treatment they need."

Once in jail, the mentally ill generally do not fare well. Mental disorders place them at increased risk of suicide and being victimized or sexually abused. Several studies have shown that at least half of all inmates who committed suicide either had a major mental disorder at the time or had been hospitalized for one in the past. Since many disordered inmates have no insight into their illnesses, they can reject treatment and medication and can become extremely disruptive without meeting the criteria for hospitalization. Jail administrators "hate these people," says Teplin. "They are a pain in the ass to deal with. They set fires. Other prisoners hate them, and they get picked on all the time. They cause fights."

Timothy Williams says that while in prison he "didn't behave like other inmates did. I would throw feces and eat them." Jail guards, who sometimes have no mandated mental health training, can issue symptomatic inmates disciplinary tickets that lead to their incarceration for longer periods.

Unlike many inmates, the mentally ill usually serve out their jail terms, largely because the courts don't consider them good candidates for work-release or other alternatives to incarceration programs. Periods of hospitalization are sometimes not counted toward time served on sentences; sick detainees with no insight can be hospitalized multiple times, extending their jail time by months.

When mentally ill inmates are finally released, jails often don't engage in discharge planning. A study Vesey conducted in 1997 revealed that only 20 percent of jails do so nationwide, while a 1992 jail study found that 46 percent of respondents were unaware of whether their disordered inmates received follow-up care in the community.

The 1992 survey also estimated that only one-third of seriously mentally ill inmates received continuing psychiatric services once they left jail. "I think jails still really think that they stand alone," says Vesey, "that they have a criminal justice mission that picks up as soon as people walk through the door, and that they have no other responsibilities as soon as the person walks out the door."

Fearing life on the street without medication, Williams says he tried to lengthen his prison term by threatening to punch a guard. His behavior illustrates how psychiatric aftercare is the gravest problem an inmate with mental illness faces upon release. The mentally ill sometimes must wait between one and two months to be seen by a clinic after leaving jail.

Another barrier to treatment is that if jail mental health service providers are different from those in the community, then confidentiality laws prevent psychiatric histories and other medical records from being shared. Jail and community mental health workers may diagnose inmates differently and prescribe different medications. "So it's as if everyone's starting with a clean slate," says Vesey. "And this has everything to do with jail staff not being able to communicate with community staff."

The breakdown in communication between jails and community mental health groups can have serious ramifications for public safety. Jails have an embarrassing history of releasing mentally disordered inmates with a history of violence without arranging for any follow-up treatment. While medicated, people with mental disorders are no more prone to aggression than the general population. However, without medication, some mentally ill people can become violent.

The University of Southern California's H. Richard Lamb conducted a 1987 study of eighty-five mentally ill felons--more than half of whom had committed violent crimes and were found not competent to stand trial. The study revealed that 42 percent had been released from jail with no plans for follow-up treatment. And while violence is difficult to predict, there is evidence that a history of violent behavior among the mentally ill is a good indicator of future behavior. A 1989 study of outpatients from a Kansas City mental health center, reported in Psychological Assessment, revealed that between 25 and 30 percent of men with at least one violent incident in their past were violent within a year of release from the center.

Counties recognizing that mentally ill offenders are a community issue--not just the responsibility of jails or public mental health agencies--stand the best chance of offering humane treatment. Some jurisdictions are experimenting with diversion programs, establishing twenty-four-hour psychiatric crisis centers where police can bring people they would otherwise arrest. Other counties attempt to sustain continuity of care and get around confidentiality laws by maintaining the same mental health providers in the jails as in the community.

The AADC mental health program is used as a demonstration project by the National Institute of Corrections, a federal agency providing assistance to jails and prisons. The jail's program is administered by the City of Alexandria Community Services Board, which also oversees mental health care in the city. The sheriff's department, which administers the jail, splits the cost of care for mentally ill offenders with the Community Services Board. Seven mental health workers oversee a psychiatric housing area in the jail, which holds 410 people. Case managers within the Community Services Board's mental health and substance abuse offices know some AADC inmates before incarceration, explains William Gimblett, director of the jail's mental health services. "So when they learn that someone they know has come to the jail," he says, "they are in touch with the staff here to collaborate on their treatment plan."

When inmates finish their time at the AADC, jail staff contact community care providers to ensure they are alerted. According to Undersheriff Richard Ruscak, who oversees the jail, the program is effective because it quickly links mental health services to offenders. "They used to get arrested" and the county department of mental health "wouldn't know they were in jail," he says. "Mental health just thought they were out on the street and not coming back for therapy. But now that it's known that they're in jail, service linkage is much quicker."

Unfortunately, there is only so much a jail program can do. Because of his rash of burglaries, Williams will serve a six-year sentence. "When I go to the penitentiary I'll try to find someone there who can hook me up with a community program, group home, or something," he says. "If I don't [hook up] all I can do is a lot of praying that I don't end up walking the streets again."

Spencer P. M. Harrington is a freelance writer. He has attended John Jay College of Criminal Justice in New York and worked as a senior editor at Archaeology magazine for ten years. This article was written with the support of a grant from the Dick Goldensohn Fund, which supports investigative journalism.