Insane America's criminal treatment of mental illness

IN 1946, Life magazine published an exposé that declared most American mental hospitals "a shame and a disgrace." The report, by Albert Q. Maiséi, featured scathing anecdotes of routine abuse, starvation diets, overcrowded bathrooms and cynical charades of treatment that mocked the very word. "Through public neglect and legislative penny-pinching, state after state has allowed its institutions for the care and cure of the mentally sick to degenerate into little more than concentration camps," Maiséi wrote. Some 70 years later, the journalist Alisa Roth has written a chilling book that argues that American jails and prisons have become de facto warehouses for the mentally ill, and that conditions inside have hardly improved from the horrors Maiséi uncovered. More than half the prisoners incarcerated in America suffer from some kind of mental illness, Roth writes. She cites a federal study that says 75 percent of women locked up are mentally ill. Yet the American prison system is woefully unprepared to offer treatment or provide even basic mental health care to its wards. The poor conditions inside are in fact making the sick even sicker. "We're not psychiatrists," Alejandro Fernandez, a Los An inmate Angeles corrections official, tells Roth in one of the book's many interviews with front-line observers. "We, as deputies, we know how to arrest people. We know how to put people in jail. We don't know how to take care of people with mental illness." Much has been written in recent years about the brutal racial disparity in American incarceration that has locked away generations of black men at a rate dramatically outpacing that of whites. Michelle Alexander makes the case as pointedly as anyone that mass incarceration is, as she calls it, "The New Jim Crow." In "Insane," Roth is looking to frame the incarceration and treatment of the mentally ill as the next civil rights issue. Roth traces the long history of how we ended up with millions of incarcerated patients all the way back to Benjamin Franklin and the founding of the Republic. America has never quite known what to do with the mentally ill, and Roth argues that the latest solution - lock them up! - is the worst option of all: morally wrong, medically wrong and economically wrong. "We continue to treat people with mental illness almost exactly as we did before electricity was invented, before women had the right to vote and before the abolition of slavery," she writes. "Locking up vulnerable people in inhumane conditions is fundamentally immoral." Roth paints a devastating portrait of lives wrecked - or ended - in prisons, stories of sick people who never got the treatment they needed outside, and certainly didn't receive it on the inside either. It's hard to read "Insane" without concluding that the way the criminal justice system has dealt with mental illness is profoundly broken, and that its flaws have led to tremendous anguish. There's the mentally ill Virginia man, arrested for stealing $5 of junk food, who was treated by corrections officers "like a circus animal." He died in jail, apparently of starvation. There's the Florida man diagnosed with schizophrenia who fouled his cell with his own feces; he was punished with a "special" shower turned up to 160 degrees that practically boiled him alive over two hours, killing him. As Roth writes movingly of the human toll of incarceration, there's a central tension in the book between society's desire to punish lawbreakers, and the responsibility to care for the sickest among us. She argues that most mentally ill prisoners would be better served outside the prison system, and that most prisons would be cheaper and easier to manage without such a sick population. She convincingly diagnoses the glaring inadequacies of mental health treatment in prison - she cites a Pennsylvania penitentiary where treatment consisted of distributing coloring books - but she is not out for scapegoats. In fact, she writes sympathetically about prison officials being asked to do difficult, specialized work for which they're woefully unequipped. A dogged reporter who worked for years on the radio show "Marketplace," Roth crisscrossed the country visiting jails and prisons. At times she lets her passion steer her arguments. She writes sympathetically of an Alabama prisoner "who was barely five feet tall and slight, and, apart from having shot his mother, his only significant history of violence was against himself." That's a pretty big "apart." Roth argues that many mentally ill prisoners are in jail for misdemeanors and minor violations like shoplifting or loitering, crimes that should have alerted mental health providers rather than pointed them toward prison. She ends a visit to a Los Angeles jail with this stark description: "thousands of desperately sick people receiving minimal treatment for their mental health problems, being cared for by people with little training for that aspect of the job, and all this at great expense - simply because they have been charged with a crime." "Insane" is rife with sharp, brutal details that pull the reader beyond the realms of abstract policy debates. Roth describes the smell of jail: "The pungency depends in part on how often the occupant is willing to submit to a shower and how many old milk cartons he is saving in his cell (a common practice) and whether his particular demons compel him to smear the wall with feces." She describes a corrections officer who nonchalantly shows her a small hooked blade that hangs from his belt loop. He tells her it's a special tool for "cutting down" - rescuing people who have tried to hang themselves. While Roth writes accessibly, her book can at times read like a study of Prison Best Practices as she compares the efficacy of various Rikers Island clinics with guidelines from the American Psychiatric Association. She mitigates this with collections of thumbnail profiles, most of them shattering, about mentally ill people made worse by the prison system. After so much despair, Roth ends with several promising examples from around the country where the intersection of mental illness and criminal justice has not proved devastating. Most interesting perhaps is the case of Steve Leifman, a Florida judge who runs a jail diversion program with a simple premise: When a person with a mental illness is arrested for a nonviolent misdemeanor, he or she can be steered toward treatment rather than criminal court. The vast majority opt for treatment, where they are connected with housing and other services. Recidivism is low, patients get the support they need, and the prison system saves significant funds. Leifman says that over the last decade he has managed to steer some 4,000 people out of the criminal justice system. That may sound like a small number compared with the scale of the national incarceration problem, and it is. But by the end of "Insane," you are so aware of the suffering that just one mentally ill prisoner could endure that it's a relief to look for hope where you can find it. One federal study reports that 75 percent of women in jail are mentally ill. SAM dolnick is an assistant managing editor at The Times.

Marketplace reporter Roth's cri de coeur uses moving anecdotes of how the American criminal justice system treats the mentally ill to make the problem palpable. Roth provides a deeply disturbing synthesis of her research, both academic and in the field, including conversations with professionals, and the mentally ill, to show how despite the increased understanding of mental illness over the last two centuries, and apart from the development of more effective medications, "we continue to treat people with mental illness almost exactly as we did before electricity was invented." In one of the more unsettling examples, a businessman and former firefighter with bipolar disorder was arrested for indecent exposure after he stripped naked in the hallway of a hotel when he was unable to open the door to his room. Later, when he turned violent, correction officers with no access to his medical records or understanding of the care he needed put him in solitary confinement. Roth proposes sound alternatives, such as San Antonio's investment in a 24/7 crisis center devoted to keeping people with mental illness "out of the criminal justice system and [getting them] into effective treatment." Roth strikes a powerful balance between big picture analysis and individual stories to make this searing account of America's misguided treatment of the mentally ill hard to ignore. (Apr.) © Copyright PWxyz, LLC. All rights reserved.