Fifty years ago half a million of us lived in public mental health hospitals, some voluntary but many against their will. How is it that today, by some estimates, only approximately 80,000 of us are in these hospitals? And where are the mentally ill today if not in hospitals?
The introduction of successful anti-psychotic drugs in the 1960s meant that the mentally ill could be treated as outpatients in community mental health centers. The resulting massive closure of state mental hospitals, “deinstitutionalization,” was fueled by increasing awareness of the infringement of liberties inherent in involuntary hospitalization. The federal government provided funds for the establishment of community centers. States cut funds for their mental hospitals but declined to provide the money for continuing care and the community center concept died a quick death.
Patients who had spent decades or entire lives in state hospitals now had to fend for themselves. Those who could enter the few community centers or had families to whom they could turn were fortunate. Many found themselves homeless, cut off from the support they had received in the hospitals as well as medication that might enable them to function. Not that state hospitals were country clubs: the care was frequently ineffectual and often brutal. But it could hardly have been more brutal than life on the street, where the mentally ill are often victimized. Only those who are deemed to be a threat to themselves or to others can receive treatment – if they can find it. When they do, it is almost always short-term; released as soon as they are stabilized, they receive no follow-up care.
A generally accepted figure for the number of mentally ill in the general population is 5 percent. Of these perhaps 5 or 10 percent are seriously mentally ill. By contrast, 20 to 33 percent of today’s homeless are thought to be seriously mentally ill. They are far more likely to have been homeless longer than others. They often commit minor offenses in order to be jailed: cycling in and out of jail may not get them treatment, but it provides a place to sleep and a few meals. There the only treatment they receive is that meant to keep them docile and obedient. It can be anything from pepper spray to beatings and chaining. The mentally ill individual may cycle in and out of jail indefinitely depending on the degree of illness and the need for shelter and food or both.
When, homeless or not, their behavior is sufficiently out of touch with reality they often commit crimes of violence which land them in prison. Frequently confined in isolation, they are even less able to function than in the outside world. When their aberrant behavior is found to violate prison rules they are further castigated, which only exacerbates their condition. They receive minimal treatment if any at all and, if their conditions worsen so that they become more recalcitrant and violent, they often face beatings, various forms of restraint and further isolation.
In mid-2002 there were approximately 665,500 people in this country’s jails, about a third of the total number of approximately 2,020,000 incarcerated individuals. According to a recent Human Rights Watch report (“Ill-Equipped: U.S. Prisons and Offenders with Mental Illness”), “somewhere between 8 and 19 percent of prisoners [between 161,600 and 383,800 individuals] have significant psychiatric or functional disabilities.” The report cites the American Psychiatric Association (APA) finding that perhaps as many as one prisoner in five is seriously mentally ill. Of these more than 70,000 are psychotic.
It may be less expensive as well as better for the mentally ill to be treated in a community facility; it is far more expensive to “treat” them in prison or jail – consider overtime by guards, hospital stays, broken property and cleanup of biohazards like blood and feces. The average jail prisoner costs a jurisdiction around $90 a day; a mentally ill prisoner may cost the taxpayer as much as 10 or 12 times that. And this cost is not for treatment but rather for containment.
Prisons and jails have become warehouses for the mentally ill. According to the APA, some 700,000 mentally ill are processed annually in the criminal justice system. It has been estimated that between 25 and 40 percent of our mentally ill will eventually be processed. The number of imprisoned mentally ill is three times the number hospitalized, according to NAMI, (formerly the National Alliance for the Mentally Ill). Incarceration under any circumstances is difficult; for the mentally it often becomes torture plain and simple. This situation can only raise once again the question: just what are our national priorities?
Julia Lutsky is a reader in New York City. She can be reached at firstname.lastname@example.org.