Duty of Care

Twin Towers Correctional Facility. Jjz3d83 at the English-language Wikipedia, CC BY-SA 3.0 <http://creativecommons.org/licenses/by-sa/3.0/>, via Wikimedia Commons

Roth goes on to examine the history of psychiatric care in America, tracing the process of deinstitutionalization through, first, the invention of Thorazine in 1954, which led to a reliance on antipsychotic medication. Secondly, she points to Kennedy’s Mental Retardation Facilities and Community Health Center Construction Act, a bill which reduced the number of psychiatric institutions, proposing community care centers to replace them (unfortunately, many of these community care centers were either never built or did not serve the populations that most needed them). In 1965, Medicaid and Medicare were created, making states responsible for psychiatric care rather than federal governments. But Medicaid wouldn’t cover patients under age 65 in psychiatric facilities, leading many patients to be moved to outpatient care and nursing homes. Roth theorizes that people with mental illness have been caught up by the same factors that have contributed to the overall rise of mass incarceration; that since the 1970s, we have given up on the idea of incarceration as rehabilitative; and that we are more willing to spend money on ‘public safety’ than on public health.

A major problem in caring for people with mental illness in jails and prisons is that these facilities are often treating the patients who are the sickest and have received minimal care prior to incarceration, with the added complication that substance abuse commonly cooccurs with these issues. Despite women making up a minority of the incarcerated population, those suffering from mental illness often have the worst outcomes, as their incarceration often has far-reaching consequences for those with children such as temporary custody loss or infrequent contact.

There are numerous instances of mentally ill people dying due to torture at the hands of corrections officers. One such example is the tragic case of Jamycheal Mitchell, who was arrested in April 2015 for stealing five dollars’ worth of junk food. He spent four months in jail awaiting a transfer, during which time he died of starvation because officers had turned off his water, he was rarely fed or given meds, had no clothes, mattresses, sheets, or blankets, and his cell was covered in urine and feces. Solitary confinement is a common way in which incarcerated people with mental illnesses are subject to torture and abuse.

In addition to higher rates of self-harm for incarcerated people in solitary confinement, there is also a general lack of mental healthcare. When incarcerated people are placed in solitary confinement, individual therapy is often conducted cell-side, meaning there is no privacy and communication is difficult. Although there are rules that often preclude incarcerated people with mental illnesses from being put into solitary confinement, there are tactics that correctional facilities use to get around these regulations. In addition, when caring for patients in carceral facilities, there is the problem of dual loyalty for medical staff, who must rely on security personnel for their own safety, which can result in considering staff over patients.

Roth also reveals that pleading ‘Not Guilty By Reason of Insanity’ is extremely uncommon. Our skepticism about people who attribute their behavior to mental health issues has contributed to this defense being viewed as controversial. More commonly, a defendant is deemed ‘unfit to stand trial.’ In this case, the defendant is referred to a treatment called ‘restoration to competency’ where medications are administered and classes are given that repeat basic facts about the court. In several states, part of this dubious process is making defendants watch shows such as Law and Order. Aside from the issue of whether the process is effective, people who are undergoing this process are taking up valuable forensic beds in psychiatric hospitals. Many defendants become caught up in a cycle whereby during the time that they are awaiting their trail in jail, they become unstable and are again deemed incompetent.

Roth argues that, in America, we desperately need more outpatient mental healthcare. Community mental health care centers face limited budgets, meaning they must regularly turn away patients and release those who are under their care quickly. People with serious mental illnesses are also often continually rearrested; in New York, frequently arrestees were more than twice as likely to have a serious mental illness and a majority also had substance issues. Frequent arrestees fitting this description were most often facing charges of petit larceny or criminal possession of a controlled substance. Through examining this population, the link between poverty, mental illness, and crimes of economic stress becomes clear.

Roth also addresses the tragic fact that many people suffering from a mental illness are killed by the police. A major issue in how we respond to mental health crises is that police are generally the ones responding rather than EMTs. Police are trained to make themselves look threatening, and for someone suffering from mental illness, this approach can be terrifying. Unfortunately, although police are most often the ones responding to mental health-related calls, they receive little training on working with the people they encounter. This can result in tragic fatalities such as that of Keith Vidal, an eighteen year-old man with schizophrenia and depression. His parents found him in a confused state and called 911. EMTs came to the scene but were told to wait while the police assessed the situation. Vidal had a screwdriver in his hands but was calm. The officer ordered that he be tased and seconds later, he fatally shot Vidal.

One response to the problem of responding to mental health crises has been Crisis Intervention Team training for police officers. CIT teaches tactics for defusing situations, which can lead to better outcomes. Roth also points to social service centers as a way to keep people from mental illness out of jail. Jail diversion programs such as the Criminal Mental Health Project can also work to connect mentally ill people who are arrested on misdemeanors and some nonviolent felony charges to mental health care and housing resources.Ultimately, Insane illuminates the many cracks within our broken mental healthcare system, demonstrating how the rise of mass incarceration has exacerbated an existing crisis, making prisons and jails our largest de facto providers of mental health care. Roth shows how ill-equipped carceral institutions are to provide this service and asks us to reflect on whether the conflicting motives of mental health care and incarceration can even be reconciled. While solutions have been explored to remedy the issue, the problem requires a long-term systemic approach that attempts to address our underinvestment in mental health care.

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Unfortunately, the book requests we receive at BBB often reflect the inadequate care that incarcerated people receive for mental health issues, revealing how many are left on their own to find solutions for their unmet needs. We also receive letters from people in solitary confinement for whom reading is the only thing they say is keeping them sane. We are proud to provide mental health-related resources to those who need them, but we ultimately realize that it can never be enough. As long as prisons and jails are the largest providers of mental health care in America, the system is clearly failing some of the most vulnerable members of our communities.