Author: Alisa Roth
APA Style Citation
Roth, A. (2018). Insane: America’s criminal treatment of mental illness. New York, NY: Basic Books.
Buy This Book
Roth estimates that as many as 50% of all people in the criminal justice system suffer from some type of mental illness. Some are there because of a crime committed while others are there because of a severe shortage of beds available in mental health care facilities. These statistics are startling, and Roth describes the personal stories of individuals with mental illness, making the real-life implications of this hit home. Instead of accessing treatment through the mental health care system, often, those who are mentally ill face extended prison time for the behavior associated with their illness. Many of the mentally ill are initially arrested on minor infractions such as Bryan Sanderson, who was arrested for riding a hotel elevator naked after voices told him to leave his room immediately. Unfortunately, these minor infractions often lead to long prison terms because of violations of prison rules due to their illness. If someone is experiencing auditory hallucinations, for example, these voices may take precedent over a direct order coming from a correctional officer. Sanderson ultimately was placed in solitary confinement for a time because his illness prevented him from following simple prison protocols. In addition, his hallucinations and delusions caused him to lash out at others, and he was considered a danger on the prison ward. The incident in the elevator should have led to an straight-forward overnight stint in jail as nobody was harmed, but Sanderson’s voices ultimately told him to blind himself while he was held in solitary because his illness was not being managed. After he blinded himself, he was taken to a regular hospital, but after he was healed, it was determined that he could be sent back to prison. He was finally released after years in prison. Today, he lives alone but is entirely dependent on the help of family and friends to bring him groceries and other necessities, and he cannot work.
Roth addresses the shrinking number of beds in mental health care facilities. The reduction in beds started to occur about the time that antipsychotic medication allowed many schizophrenic patients to live relatively normal lives in which institutionalization was no longer necessary. With no place to go, many of the mentally ill wind up incarcerated. The sad reality is that most prisons are not well equipped or trained to deal with a population of those who are mentally ill.
By sheer necessity, prison systems operate by strict rules and adherence to stringent routine. The loud, chaotic environment of prisons can be terribly disturbing for those who may already be dealing with auditory or visual hallucinations. Those who are mentally ill often do not fare well in this environment, and their condition often deteriorates. Some prison facilities offer a mental health wing, but there are a limited number of cells. The waiting lists are often long, and it is frustrating to get into these units if they even exist.
Treatment on mental health wards is often severely lacking, and most prisoners are chained to a seat while they receive their therapy sessions with a psychologist. Other times treatment is canceled because there is a shortage of clinicians or if the prison is in lockdown mode, the sessions are canceled because all of the prison staff is needed to maintain the safety of the entire prison population. In most places such as the Los Angeles prison system Roth describes time with mental health professionals as “medication management,” not treatment.
The prison staff who may have the best of intentions are often not properly trained to deal with individuals who are mentally ill and showing signs of severe mental illness is often deemed as disobedient. Those who thought they were going into a career of law enforcement now find themselves on the front line of treating mental illness without the proper training. Obviously, the prison staff need to keep themselves safe, but law enforcement training escalates a situation, whereas a person with mental illness needs de-escalation of the situation.
Without proper treatment and in an environment in which people feel threatened, those with mental illness may lash out in anger and frustration, which furthers the cycle of punishment in prison. The mentally ill who eventually leave prison facilities are often worse off than when they entered and have few resources to help them get back to a normal daily life. In large part, this impacts male African Americans in higher numbers than other groups.
Prisoners can be forced to take medication, and while they do not have to attend treatment sessions if they are offered, the incentive to attend is high in the prison population because of the nature of the prison environment in which prisoners are expected to comply. In the worst cases, those who are victims of the system take their own lives in prison or like Bryan Sanderson cause themselves severe bodily harm. Many people spend extended time in prison waiting for a trial to determine if they are competent. Spending more time in prison often makes the individual less likely to qualify for competency, leaving many lingering in prisons for weeks or months just to determine if they are fit to stand trial. These inmates are coached by lawyer and then often sent back to prison during the case without any treatment at all.
Roth ends on a more positive note as she describes how many states have increased mental illness training for law enforcement. This helps responding officers in understanding and may keep some people out of prison in the first place. Still, the training has a long way to go. Facilities and funding of prisons must increase, and treatment must be more consistent. The treatment should also take place with the same person so that a relationship can develop between therapist and inmate. Decreasing the number of people incarcerated for minor infractions and creating better facilities in which to treat individuals who might otherwise lead productive and fruitful lives should be a priority.
Other Related Resources
NPR: Fresh Air
Behind Bars, Mentally Ill Inmates Are Often Punished for Their Symptoms
Interview with Alisa Roth
APA Monitor: March 2019
Improving Mental Health for Inmate
National Commission on Correctional Health Care
Basic Mental Health Care Services
Mental Health America
Position Statement 56: Mental Health Treatment in Correctional Facilities
National Alliance on Mental Health (NAMI)
Jailing People with Mental Illness
Oregon Humanities Center
Alisa Roth: “America’s Hidden Mental Health Crisis”
Treatment Advocacy Center
Serious Mental Illness Prevalence in Jails and Prisons
Psychological Figures and Concepts